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Salman LA, Altahtamouni SB, Khatkar H, Al-Ani A, Hameed S, Alvand A. The efficacy of aspirin versus low-molecular-weight heparin for venous thromboembolism prophylaxis after knee and hip arthroplasty: A systematic review and meta-analysis of randomized controlled trials. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39228215 DOI: 10.1002/ksa.12456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2024] [Revised: 08/19/2024] [Accepted: 08/25/2024] [Indexed: 09/05/2024]
Abstract
PURPOSE The purpose of this study was to assess the efficacy of aspirin versus low-molecular-weight heparin (LMWH) in preventing venous thromboembolism (VTE) following hip and knee arthroplasty. METHODS PubMed/Medline, Embase, Cochrane Library and Google Scholar databases were searched from inception till June 2024 for original trials investigating the outcomes of aspirin versus LMWH in hip and knee arthroplasty. The primary outcome was VTE. Secondary outcomes included minor and major bleeding events, and postoperative mortality within 90 days. This review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS A total of 7 randomized controlled trials with 12,134 participants were included. The mean ages for the aspirin and LMWH cohorts were 66.6 (57.6-69.0) years and 66.8 (57.9-68.9) years, respectively. There was no statistically significant difference in the overall risk of VTE between the aspirin and the LMWH cohorts (odds ratio [OR]: 0.95; 95% confidence interval [CI]: 0.48-1.89; p: 0.877). A subanalysis based on the specific VTE entity (pulmonary embolism [PE] or deep venous thrombosis) showed a significantly higher PE risk for patients receiving aspirin than the LMWH cohort (OR: 1.79; 95% CI: 1.11-2.89; p: 0.017). There was no difference in minor (OR: 0.64; 95% CI: 0.40-1.04; p: 0.072) and major bleeding (OR: 0.77; 95% CI: 0.40-1.47; p: 0.424) episodes across both groups. Furthermore, subanalysis among the total knee arthroplasty group showed that the aspirin cohort was significantly more likely to suffer VTEs than their LMWH counterparts (OR: 1.55; 95% CI: 1.21-1.98; p < 0.001). CONCLUSION This study demonstrated a significantly higher risk of PE among patients receiving aspirin compared to LMWH following hip or knee arthroplasty for osteoarthritis. Aspirin was associated with a significantly higher overall VTE risk among patients undergoing knee arthroplasty, in particular. This might suggest the inferiority of aspirin compared to LMWH in preventing VTE following such procedures. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Loay A Salman
- Department of Orthopaedic Surgery, Surgical Specialty Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Seif B Altahtamouni
- Department of Orthopaedic Surgery, Surgical Specialty Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | - Abdallah Al-Ani
- Office of Scientific Affairs and Research, King Hussein Cancer Center, Amman, Jordan
| | - Shamsi Hameed
- Department of Orthopaedic Surgery, Surgical Specialty Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abtin Alvand
- Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
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Cheok T, Beveridge A, Berman M, Coia M, Campbell A, Tse TTS, Doornberg JN, Jaarsma RL. Efficacy and safety of commonly used thromboprophylaxis agents following hip and knee arthroplasty. Bone Joint J 2024; 106-B:924-934. [PMID: 39216864 DOI: 10.1302/0301-620x.106b9.bjj-2023-1252.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Aims We investigated the efficacy and safety profile of commonly used venous thromboembolism (VTE) prophylaxis agents following hip and knee arthroplasty. Methods A systematic search of PubMed, Embase, Cochrane Library, Web of Science, and OrthoSearch was performed. Prophylaxis agents investigated were aspirin (< 325 mg and ≥ 325 mg daily), enoxaparin, dalteparin, fondaparinux, unfractionated heparin, warfarin, rivaroxaban, apixaban, and dabigatran. The primary efficacy outcome of interest was the risk of VTE, whereas the primary safety outcomes of interest were the risk of major bleeding events (MBE) and wound complications (WC). VTE was defined as the confirmed diagnosis of any deep vein thrombosis and/or pulmonary embolism. Network meta-analysis combining direct and indirect evidence was performed. Cluster rank analysis using the surface under cumulative ranking (SUCRA) was applied to compare each intervention group, weighing safety and efficacy outcomes. Results Of 86 studies eligible studies, cluster rank analysis showed that aspirin < 325 mg daily (SUCRA-VTE 89.3%; SUCRA-MBE 75.3%; SUCRA-WC 71.1%), enoxaparin (SUCRA-VTE 55.7%; SUCRA-MBE 49.8%; SUCRA-WC 45.2%), and dabigatran (SUCRA-VTE 44.9%; SUCRA-MBE 52.0%; SUCRA-WC 41.9%) have an overall satisfactory efficacy and safety profile. Conclusion We recommend the use of either aspirin < 325 mg daily, enoxaparin, or dabigatran for VTE prophylaxis following hip and knee arthroplasty.
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Affiliation(s)
- Tim Cheok
- Department of Orthopaedic Surgery, Lyell McEwin Hospital, Adelaide, Australia
- Department of Orthopaedic Surgery, Palmerston North Hospital, Palmerston North, New Zealand
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Alexander Beveridge
- Department of Orthopaedic Surgery, Palmerston North Hospital, Palmerston North, New Zealand
- School of Medicine, Cardiff University, Neuadd Meirionnydd, Cardiff, UK
| | - Morgan Berman
- Department of Orthopaedic Surgery, Monash Medical Centre, Melbourne, Australia
| | - Martin Coia
- Department of Orthopaedic Surgery, Palmerston North Hospital, Palmerston North, New Zealand
| | - Alexander Campbell
- Department of Orthopaedic Surgery, Middlemore Hospital, Auckland, New Zealand
| | - Tycus T S Tse
- Department of Orthopaedic Surgery, Palmerston North Hospital, Palmerston North, New Zealand
| | - Job N Doornberg
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Department of Orthopaedic Surgery, Flinders Medical Centre, Adelaide, Australia
- Department of Orthopaedic Surgery, University Medical Centre Groningen, Groningen, Netherlands
| | - Ruurd L Jaarsma
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Department of Orthopaedic Surgery, Flinders Medical Centre, Adelaide, Australia
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Núñez JH, Moreira F, Escudero-Cisneros B, Martínez-Peña J, Bosch-García D, Angles F, Guerra-Farfán E. [Translated article] Risk of venous thromboembolism in thromboprophylaxis between aspirin and low molecular weight heparins after total hip arthroplasty or total knee arthroplasty: Systematic review and meta-analysis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:T409-T421. [PMID: 38325570 DOI: 10.1016/j.recot.2024.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/16/2023] [Accepted: 07/27/2023] [Indexed: 02/09/2024] Open
Abstract
INTRODUCTION The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA). MATERIALS AND METHODS Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analysed. Mortality, risk of bleeding and surgical wound complications was also analysed. RESULTS 248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR=0.93; 95% CI: 0.69-1.26; p=0.64), DVT (OR=0.72; 95% CI: 0.43-1.20; p=0.21) or PE (OR=1.13; 95% CI: 0.86-1.49; p=0.38) between both groups. No significant differences were found in mortality (p=0.30), bleeding (p=0.22), or complications in the surgical wound (p=0.85) between both groups. These same findings were found in the sub-analysis of only randomised clinical trials (p>0.05). CONCLUSIONS No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis.
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Affiliation(s)
- J H Núñez
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Plaça del Doctor Robert, 5, 08221 Terrassa, Barcelona, Spain; Artro-Esport, Centro Médico Teknon, Carrer de Vilana, 12, 08022 Barcelona, Spain.
| | - F Moreira
- Artro-Esport, Centro Médico Teknon, Carrer de Vilana, 12, 08022 Barcelona, Spain
| | - B Escudero-Cisneros
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Plaça del Doctor Robert, 5, 08221 Terrassa, Barcelona, Spain
| | - J Martínez-Peña
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Plaça del Doctor Robert, 5, 08221 Terrassa, Barcelona, Spain
| | - D Bosch-García
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Plaça del Doctor Robert, 5, 08221 Terrassa, Barcelona, Spain
| | - F Angles
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Plaça del Doctor Robert, 5, 08221 Terrassa, Barcelona, Spain
| | - E Guerra-Farfán
- Artro-Esport, Centro Médico Teknon, Carrer de Vilana, 12, 08022 Barcelona, Spain
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Shibuya N, Zimmer C, Jupiter DC. Venous Thromboembolism in Foot and Ankle Trauma. Clin Podiatr Med Surg 2024; 41:607-617. [PMID: 38789173 DOI: 10.1016/j.cpm.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Every surgeon may have experienced a tragic event associated with death or debilitation secondary to deep vein thrombosis (DVT) or pulmonary embolism (PE) after foot and ankle trauma and surgery. Nevertheless, the prevention of such a tragic event needs to be carefully evaluated rationally with currently available epidemiologic data. With great postoperative protocols and access to care, most PE events can be prevented. There are modifiable risk factors, such as length/type of immobilization and operative trauma/time that can lower the incidence of DVT/PE. In addition, chemical prophylaxis may be warranted in certain people within the foot and ankle trauma population.
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Affiliation(s)
- Naohiro Shibuya
- Department of Medicine, University of Texas Rio Grande Valley, School of Podiatric Medicine.
| | - Christopher Zimmer
- Department of Podiatric Medicine and Surgery, Baylor Scott and White Memorial Hospital, Texas A&M Health Science Center
| | - Danial C Jupiter
- Department of Biostatistics and Data Science, Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch
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Núñez JH, Moreira F, Escudero-Cisneros B, Martínez-Peña J, Bosch-García D, Anglès F, Guerra-Farfán E. Risk of venous thromboembolism in thromboprophylaxis between aspirin and low molecular weight heparins after total hip arthroplasty or total knee arthroplasty: Systematic review and meta-analysis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:409-421. [PMID: 37544408 DOI: 10.1016/j.recot.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/16/2023] [Accepted: 07/27/2023] [Indexed: 08/08/2023] Open
Abstract
INTRODUCTION The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA). MATERIALS AND METHODS Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analyzed. Mortality, risk of bleeding and surgical wound complications was also analyzed. RESULTS 248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR = 0.93; 95% CI: 0.69-1.26; P = .64), DVT (OR = 0.72; 95% CI: 0.43-1.20; P = .21) or PE (OR = 1.13; 95% CI: 0.86-1.49; P = .38) between both groups. No significant differences were found in mortality (P = .30), bleeding (P = .22), or complications in the surgical wound (P = .85) between both groups. These same findings were found in the sub-analysis of only randomized clinical trials (P>.05). CONCLUSIONS No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis.
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Affiliation(s)
- Jorge H Núñez
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Terrassa, Barcelona, España; Artro-Esport, Centro Médico Teknon, Terrassa, Barcelona, España.
| | - Felipe Moreira
- Artro-Esport, Centro Médico Teknon, Terrassa, Barcelona, España
| | - Berta Escudero-Cisneros
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Terrassa, Barcelona, España
| | - Judith Martínez-Peña
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Terrassa, Barcelona, España
| | - David Bosch-García
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Terrassa, Barcelona, España
| | - Francesc Anglès
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Terrassa, Barcelona, España
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Harris IA, Sidhu VS, MacDessi SJ, Solomon M, Haddad FS. Aspirin for thromboembolic prophylaxis. Bone Joint J 2024; 106-B:642-645. [PMID: 38946290 DOI: 10.1302/0301-620x.106b7.bjj-2024-0621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Affiliation(s)
- Ian A Harris
- School of Clinical Medicine, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia
- Institute of Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, Australia
| | - Verinder S Sidhu
- School of Clinical Medicine, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Samuel J MacDessi
- School of Clinical Medicine, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
- Orthopaedic Department, St George Private Hospital, Sydney, Australia
| | - Michael Solomon
- Orthopaedic Department, Prince of Wales Hospital, Sydney, Australia
- Faculty of Medicine and Health Sciences, University of New South Wales, Randwick, Australia
| | - Fares S Haddad
- The Bone & Joint Journal , London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
- The Princess Grace Hospital, London, UK
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Aspirin or enoxaparin for VTE prophylaxis after primary partial, total or revision hip or knee arthroplasty: A secondary analysis from the CRISTAL cluster randomized trial. PLoS One 2024; 19:e0298152. [PMID: 38626226 PMCID: PMC11020928 DOI: 10.1371/journal.pone.0298152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/09/2024] [Indexed: 04/18/2024] Open
Abstract
BACKGROUND This study compares aspirin to enoxaparin for symptomatic VTE prophylaxis within 90 days of any type of hip or knee arthroplasty performed for any diagnosis, in patients enrolled in the CRISTAL trial. MATERIALS AND METHODS CRISTAL was a cluster-randomised crossover, registry-nested non-inferiority trial across 31 hospitals in Australia. The primary publication was restricted to patients undergoing primary total hip or knee arthroplasty for a diagnosis of osteoarthritis. This report includes all enrolled patients undergoing hip or knee arthroplasty procedures (partial or total, primary or revision) performed for any indication. Hospitals were randomized to administer patients aspirin (100mg daily) or enoxaparin (40mg daily), for 35 days after hip arthroplasty and 14 days after knee arthroplasty. Crossover occurred after the patient enrolment target had been met for the first group. The primary outcome was symptomatic VTE within 90 days. Analyses were performed by randomization group. RESULTS Between April 20, 2019 and December 18, 2020, 12384 patients were enrolled (7238 aspirin group and 5146 enoxaparin). Of these, 6901 (95.3%) given aspirin and 4827 (93.8%) given enoxaparin (total 11728, 94.7%) were included in the final analyses. Within 90 days, symptomatic VTE occurred in 226 (3.27%) aspirin patients and 85 (1.76%) enoxaparin patients, significant for the superiority of enoxaparin (estimated treatment difference 1.85%, 95% CI 0.59% to 3.10%, p = 0.004). Joint-related reoperation within 90 days was lower in the enoxaparin group (109/4827 (2.26%) vs 171/6896 (2.47%) with aspirin, estimated difference 0.77%; 95% CI 0.06% to 1.47%, p = 0.03). There were no significant differences in the other secondary outcomes. CONCLUSION In patients undergoing hip or knee arthroplasty (of any type, performed for any indication) enrolled in the CRISTAL trial, aspirin compared to enoxaparin resulted in a significantly higher rate of symptomatic VTE and joint-related reoperation within 90 days. These findings extend the applicability of the CRISTAL trial results. TRIAL REGISTRATION Anzctr.org.au, identifier: ACTRN12618001879257.
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Horner DE, Davis S, Pandor A, Shulver H, Goodacre S, Hind D, Rex S, Gillett M, Bursnall M, Griffin X, Holland M, Hunt BJ, de Wit K, Bennett S, Pierce-Williams R. Evaluation of venous thromboembolism risk assessment models for hospital inpatients: the VTEAM evidence synthesis. Health Technol Assess 2024; 28:1-166. [PMID: 38634415 PMCID: PMC11056814 DOI: 10.3310/awtw6200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Background Pharmacological prophylaxis during hospital admission can reduce the risk of acquired blood clots (venous thromboembolism) but may cause complications, such as bleeding. Using a risk assessment model to predict the risk of blood clots could facilitate selection of patients for prophylaxis and optimise the balance of benefits, risks and costs. Objectives We aimed to identify validated risk assessment models and estimate their prognostic accuracy, evaluate the cost-effectiveness of different strategies for selecting hospitalised patients for prophylaxis, assess the feasibility of using efficient research methods and estimate key parameters for future research. Design We undertook a systematic review, decision-analytic modelling and observational cohort study conducted in accordance with Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines. Setting NHS hospitals, with primary data collection at four sites. Participants Medical and surgical hospital inpatients, excluding paediatric, critical care and pregnancy-related admissions. Interventions Prophylaxis for all patients, none and according to selected risk assessment models. Main outcome measures Model accuracy for predicting blood clots, lifetime costs and quality-adjusted life-years associated with alternative strategies, accuracy of efficient methods for identifying key outcomes and proportion of inpatients recommended prophylaxis using different models. Results We identified 24 validated risk assessment models, but low-quality heterogeneous data suggested weak accuracy for prediction of blood clots and generally high risk of bias in all studies. Decision-analytic modelling showed that pharmacological prophylaxis for all eligible is generally more cost-effective than model-based strategies for both medical and surgical inpatients, when valuing a quality-adjusted life-year at £20,000. The findings were more sensitive to uncertainties in the surgical population; strategies using risk assessment models were more cost-effective if the model was assumed to have a very high sensitivity, or the long-term risks of post-thrombotic complications were lower. Efficient methods using routine data did not accurately identify blood clots or bleeding events and several pre-specified feasibility criteria were not met. Theoretical prophylaxis rates across an inpatient cohort based on existing risk assessment models ranged from 13% to 91%. Limitations Existing studies may underestimate the accuracy of risk assessment models, leading to underestimation of their cost-effectiveness. The cost-effectiveness findings do not apply to patients with an increased risk of bleeding. Mechanical thromboprophylaxis options were excluded from the modelling. Primary data collection was predominately retrospective, risking case ascertainment bias. Conclusions Thromboprophylaxis for all patients appears to be generally more cost-effective than using a risk assessment model, in hospitalised patients at low risk of bleeding. To be cost-effective, any risk assessment model would need to be highly sensitive. Current evidence on risk assessment models is at high risk of bias and our findings should be interpreted in this context. We were unable to demonstrate the feasibility of using efficient methods to accurately detect relevant outcomes for future research. Future work Further research should evaluate routine prophylaxis strategies for all eligible hospitalised patients. Models that could accurately identify individuals at very low risk of blood clots (who could discontinue prophylaxis) warrant further evaluation. Study registration This study is registered as PROSPERO CRD42020165778 and Researchregistry5216. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127454) and will be published in full in Health Technology Assessment; Vol. 28, No. 20. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Daniel Edward Horner
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Oxford Road, Manchester, UK
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Helen Shulver
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Hind
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Saleema Rex
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Michael Gillett
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matthew Bursnall
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Xavier Griffin
- Barts Bone and Joint Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark Holland
- School of Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, Bolton, UK
| | - Beverley Jane Hunt
- Thrombosis & Haemophilia Centre, St Thomas' Hospital, King's Healthcare Partners, London, UK
| | - Kerstin de Wit
- Department of Emergency Medicine, Queens University, Kingston, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shan Bennett
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Sidhu V, Badge H, Churches T, Maree Naylor J, Adie S, A Harris I. Comparative effectiveness of aspirin for symptomatic venous thromboembolism prophylaxis in patients undergoing total joint arthroplasty, a cohort study. BMC Musculoskelet Disord 2023; 24:629. [PMID: 37537580 PMCID: PMC10401792 DOI: 10.1186/s12891-023-06750-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 07/24/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND This study compares the symptomatic 90-day venous thromboembolism (VTE) rates in patients receiving aspirin to patients receiving low-molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs), after total hip (THA) and total knee arthroplasty (TKA). METHODS Data were collected from a multi-centre cohort study, including demographics, confounders and prophylaxis type (aspirin alone, LMWH alone, aspirin and LMWH, and DOACs). The primary outcome was symptomatic 90-day VTE. Secondary outcomes were major bleeding, joint related reoperation and mortality within 90 days. Data were analysed using logistic regression, the Student's t and Fisher's exact tests (unadjusted) and multivariable regression (adjusted). RESULTS There were 1867 eligible patients; 365 (20%) received aspirin alone, 762 (41%) LMWH alone, 482 (26%) LMWH and aspirin and 170 (9%) DOAC. The 90-day VTE rate was 2.7%; lowest in the aspirin group (1.6%), compared to 3.6% for LMWH, 2.3% for LMWH and aspirin and 2.4% for DOACs. After adjusted analysis, predictors of VTE were prophylaxis duration < 14 days (OR = 6.7, 95% CI 3.5-13.1, p < 0.001) and history of previous VTE (OR = 2.4, 95% CI 1.1-5.8, p = 0.05). There were no significant differences in the primary or secondary outcomes between prophylaxis groups. CONCLUSIONS Aspirin may be suitable for VTE prophylaxis following THA and TKA. The comparatively low unadjusted 90-day VTE rate in the aspirin group may have been due to selective use in lower-risk patients. TRIAL REGISTRATION This study was registered at ClinicalTrials.gov, trial number NCT01899443 (15/07/2013).
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Affiliation(s)
- Verinder Sidhu
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia.
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, Australia.
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia.
| | - Helen Badge
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia
| | - Timothy Churches
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia
| | - Justine Maree Naylor
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia
| | - Sam Adie
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia
| | - Ian A Harris
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia
- Institute of Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia
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Sidhu VS, Kelly TL, Pratt N, Graves SE, Buchbinder R, Adie S, Cashman K, Ackerman IN, Bastiras D, Brighton R, Burns AWR, Chong BH, Clavisi O, Cripps M, Dekkers M, de Steiger R, Dixon M, Ellis A, Griffith EC, Hale D, Hansen A, Harris A, Hau R, Horsley M, James D, Khorshid O, Kuo L, Lewis PL, Lieu D, Lorimer M, MacDessi SJ, McCombe P, McDougall C, Mulford J, Naylor JM, Page RS, Radovanovic J, Solomon M, Sorial R, Summersell P, Tran P, Walter WL, Webb S, Wilson C, Wysocki D, Harris IA. Effect of Aspirin vs Enoxaparin on 90-Day Mortality in Patients Undergoing Hip or Knee Arthroplasty: A Secondary Analysis of the CRISTAL Cluster Randomized Trial. JAMA Netw Open 2023; 6:e2317838. [PMID: 37294566 PMCID: PMC10257098 DOI: 10.1001/jamanetworkopen.2023.17838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/15/2023] [Indexed: 06/10/2023] Open
Abstract
Importance Ischemic heart disease remains the leading cause of mortality following hip and knee arthroplasty. Due to its antiplatelet and cardioprotective properties, aspirin has been proposed as an agent that could reduce mortality when used as venous thromboembolism (VTE) prophylaxis following these procedures. Objective To compare aspirin with enoxaparin in reducing 90-day mortality for patients undergoing hip or knee arthroplasty procedures. Design, Setting, and Participants This study was a planned secondary analysis of the CRISTAL cluster randomized, crossover, registry-nested trial performed across 31 participating hospitals in Australia between April 20, 2019, and December 18, 2020. The aim of the CRISTAL trial was to determine whether aspirin was noninferior to enoxaparin in preventing symptomatic VTE following hip or knee arthroplasty. The primary study restricted the analysis to patients undergoing total hip or knee arthroplasty for a diagnosis of osteoarthritis only. This study includes all adult patients (aged ≥18 years) undergoing any hip or knee arthroplasty procedure at participating sites during the course of the trial. Data were analyzed from June 1 to September 6, 2021. Interventions Hospitals were randomized to administer all patients oral aspirin (100 mg daily) or subcutaneous enoxaparin (40 mg daily) for 35 days after hip arthroplasty and 14 days after knee arthroplasty procedures. Main Outcomes and Measures The primary outcome was mortality within 90 days. The between-group difference in mortality was estimated using cluster summary methods. Results A total of 23 458 patients from 31 hospitals were included, with 14 156 patients allocated to aspirin (median [IQR] age, 69 [62-77] years; 7984 [56.4%] female) and 9302 patients allocated to enoxaparin (median [IQR] age, 70 [62-77] years; 5277 [56.7%] female). The mortality rate within 90 days of surgery was 1.67% in the aspirin group and 1.53% in the enoxaparin group (estimated difference, 0.04%; 95% CI, -0.05%-0.42%). For the subgroup of 21 148 patients with a nonfracture diagnosis, the mortality rate was 0.49% in the aspirin group and 0.41% in the enoxaparin group (estimated difference, 0.05%; 95% CI, -0.67% to 0.76%). Conclusions and Relevance In this secondary analysis of a cluster randomized trial comparing aspirin with enoxaparin following hip or knee arthroplasty, there was no significant between-group difference in mortality within 90 days when either drug was used for VTE prophylaxis. Trial Registration http://anzctr.org.au Identifier: ACTRN12618001879257.
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Affiliation(s)
- Verinder S Sidhu
- School of Clinical Medicine, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Thu-Lan Kelly
- Clinical and Health Sciences, Quality Use of Medicines Pharmacy Research Centre, University of South Australia, Adelaide, South Australia, Australia
| | - Nicole Pratt
- Clinical and Health Sciences, Quality Use of Medicines Pharmacy Research Centre, University of South Australia, Adelaide, South Australia, Australia
| | - Stephen E Graves
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Sam Adie
- School of Clinical Medicine, UNSW Medicine & Health, St George & Sutherland Clinical Campuses, Faculty of Medicine and Health, UNSW Sydney, New South Wales, Australia
| | - Kara Cashman
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Ilana N Ackerman
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Durga Bastiras
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Roger Brighton
- Orthopaedic Department, Westmead Private Hospital, Westmead, Sydney, New South Wales, Australia
- Orthopaedic Department, Lakeview Private Hospital, Baulkham Hills, Sydney, New South Wales, Australia
| | - Alexander W R Burns
- Orthopaedic Department, Calvary John James Hospital, Deakin, Australian Capital Territory, New South Wales, Australia
| | - Beng Hock Chong
- Department of Medicine, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Hematology, New South Wales Pathology, Kogarah Campus, Sydney, New South Wales, Australia
| | | | - Maggie Cripps
- Musculoskeletal Australia, Melbourne, Victoria, Australia
| | - Mark Dekkers
- Orthopaedic Department, Greenslopes Private Hospital, Greenslopes, Queensland, Australia
| | - Richard de Steiger
- Department of Surgery, Epworth Healthcare, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael Dixon
- Orthopaedic Department, Kareena Private Hospital, Sutherland, New South Wales, Australia
| | - Andrew Ellis
- Orthopaedic Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
| | - Elizabeth C Griffith
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - David Hale
- Orthopaedic Department, Hornsby and Kuringai Hospital, Hornsby, New South Wales, Australia
| | - Amber Hansen
- School of Clinical Medicine, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Anthony Harris
- Centre for Health Economics, Monash Business School, Monash University, Melbourne, Victoria, Australia
| | - Raphael Hau
- Department of Surgery, Epworth Healthcare, University of Melbourne, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Mark Horsley
- Orthopaedic Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Dugal James
- Bendigo Healthcare Group, Bendigo Hospital, Bendigo, Victoria, Australia
| | - Omar Khorshid
- Orthopaedic Department, Fremantle Hospital, Fremantle, Perth, Western Australia, Australia
| | - Leonard Kuo
- Orthopaedic Department, Canterbury Hospital, Canterbury, New South Wales, Australia
| | - Peter L Lewis
- Calvary Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Medical Specialties, University of Adelaide, Adelaide, South Australia, Australia
| | - David Lieu
- Orthopaedic Department, Fairfield Hospital, Fairfield, New South Wales, Australia
| | - Michelle Lorimer
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Samuel J MacDessi
- School of Clinical Medicine, UNSW Medicine & Health, St George & Sutherland Clinical Campuses, Faculty of Medicine and Health, UNSW Sydney, New South Wales, Australia
- Orthopaedic Department, St George Private Hospital, Kogarah, New South Wales, Australia
| | - Peter McCombe
- Orthopaedic Department, Frankston Hospital, Frankston, Victoria, Australia
| | - Catherine McDougall
- Orthopaedic Department, The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Jonathan Mulford
- Orthopaedic Department, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Justine Maree Naylor
- School of Clinical Medicine, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Richard S Page
- School of Medicine, St John of God Hospital and Barwon Health, Deakin University, Geelong, Australia
| | - John Radovanovic
- Orthopaedic Department, Mater Hospital, Raymond Terrace, Brisbane, Queensland, Australia
| | - Michael Solomon
- Orthopaedic Department, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Rami Sorial
- Orthopaedic Department, Nepean Hospital, Penrith, New South Wales, Australia
| | - Peter Summersell
- Orthopaedic Department, Coffs Harbour Base Hospital, Coffs Harbour, New South Wales, Australia
| | - Phong Tran
- Orthopaedic Department, Western Health, Melbourne, Victoria, Australia
| | - William L Walter
- Orthopaedic Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
- The Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Steve Webb
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- St John of God Health Care, Perth, Western Australia, Australia
| | - Chris Wilson
- Orthopaedic Department, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Department of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - David Wysocki
- Orthopaedic Department, Sir Charles Gardiner Hospital, Perth, Western Australia, Australia
| | - Ian A Harris
- School of Clinical Medicine, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- Institute of Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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Major Orthopedic Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00034-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Alsheikh K, Hilabi A, Aleid A, Alharbi KG, Alangari HS, Alkhamis M, Alzahrani F, AlMadani W. Efficacy and Safety of Thromboprophylaxis Post-Orthopedic Surgery. Cureus 2021; 13:e19691. [PMID: 34934566 PMCID: PMC8684043 DOI: 10.7759/cureus.19691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 11/29/2022] Open
Abstract
Given the high risk of venous thromboembolism (VTE) post-orthopedic surgery and the vital role of thromboprophylaxis in preventing VTEs, this meta-analysis aimed to assess the efficacy of thromboprophylaxis post major orthopedic surgery and the relevant safety measures. In this review, we conducted a computer-aided search of Google Scholar, PubMed, CINAHL, Cochrane, Medline, and EMBASE databases. We included all published randomized clinical trials (RCTs) that utilized enoxaparin, fondaparinux, dabigatran, rivaroxaban, apixaban, and aspirin for VTE prophylaxis in patients undergoing total hip arthroplasty (THA), hip fracture surgery, and total knee arthroplasty (TKA) based on primary and secondary outcomes. The Cochrane Collaboration tool was used to evaluate the risk of bias. All statistical analyses were performed using Review Manager Software. A total of 23 RCTs were included with a total sample of 48,424 patients and an overall low risk of bias. The efficacy of enoxaparin in preventing VTEs in the TKA group was significantly better than fondaparinux. In the THA group, the efficacy of enoxaparin was significantly better than apixaban. The efficacies of fondaparinux, dabigatran, rivaroxaban, apixaban, and aspirin were comparable to that of enoxaparin in reducing VTE-associated mortality, major bleeding, and adverse events. In conclusion, we found that all included drugs were non-inferior to enoxaparin in VTE-associated mortality, major bleeding, and adverse events.
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Affiliation(s)
- Khalid Alsheikh
- Department of Orthopedics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Division of Orthopedic Surgery, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, SAU
- Department of Orthopedics, King Abdullah International Medical Research Center, Riyadh, SAU
| | - Ahmed Hilabi
- Department of Orthopedics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Abdulaziz Aleid
- Department of Orthopedics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Khalid G Alharbi
- Department of Orthopedics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Hussam S Alangari
- Department of Orthopedics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Mohammed Alkhamis
- Department of Orthopedics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Faisal Alzahrani
- Department of Orthopedics, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, SAU
| | - Wedad AlMadani
- Department of Epidemiology and Public Health, General Authority for Statistics, Ministry of Economy and Planning, Riyadh, SAU
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Olukoya O, Fultang J. Aspirin Compared With Other Anticoagulants for Use as Venous Thromboembolism Prophylaxis in Elective Orthopaedic Hip and Knee Operations: A Narrative Literature Review. Cureus 2021; 13:e18249. [PMID: 34692356 PMCID: PMC8526075 DOI: 10.7759/cureus.18249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 11/05/2022] Open
Abstract
Although total hip and knee arthroplasty are effective methods for treating arthritis, they have an associated risk of venous thromboembolism (VTE). To reduce this risk, prophylactic agents including aspirin, low-molecular-weight Heparin, vitamin K antagonists, and direct oral anticoagulants are employed for up to 35 days after surgery. This narrative literature review utilised a systematic approach to critically assess the current evidence surrounding the use of aspirin for VTE prophylaxis compared to anticoagulants. An advanced multistage electronic search was performed in May 2021 using the OVID/Medline and Embase online libraries to identify available studies relevant to the subject from 1974. Additional studies identified during the review process were also included. The final studies meeting the inclusion criteria were then assessed using the Critical Appraisal Skills Programme tool. A total of 12 (60%) studies (two meta-analyses, three randomised trials, seven retrospective studies) favoured aspirin over anticoagulants for VTE prophylaxis. A total of 15 (75%) studies (two meta-analyses, three randomised trials, nine retrospective, one matched cohort) reported that aspirin had better bleeding profiles and complication rates, which was statistically significant in seven (46.7%) studies (one randomised trial, six retrospective studies). A total of eight studies (one randomised trial, six retrospective studies, one matched cohort) reported statistically significant results for aspirin. Five (62.5%) studies reported aspirin to be superior for VTE prophylaxis, while seven (87.5%) reported aspirin to be superior in terms of bleeding complications. The current evidence indicates that aspirin is superior to anticoagulants, in their various iterations, for VTE prophylaxis in terms of their bleeding profiles.
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Affiliation(s)
- Olatomiwa Olukoya
- Neurocritical Care, National Hospital for Neurology and Neurosurgery, London, GBR
| | - Joshua Fultang
- Surgery, University of Glasgow, Glasgow, GBR
- General Surgery, University Hospital Ayr/University of West of Scotland, Ayr, GBR
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15
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Sidhu VS, Kelly TL, Pratt N, Graves S, Buchbinder R, Naylor J, de Steiger R, Ackerman I, Adie S, Lorimer M, Bastiras D, Cashman K, Harris I. CRISTAL (a cluster-randomised, crossover, non-inferiority trial of aspirin compared to low molecular weight heparin for venous thromboembolism prophylaxis in hip or knee arthroplasty, a registry nested study): statistical analysis plan. Trials 2021; 22:564. [PMID: 34429127 PMCID: PMC8383378 DOI: 10.1186/s13063-021-05486-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This a priori statistical analysis plan describes the analysis for CRISTAL. METHODS CRISTAL (cluster-randomised, crossover, non-inferiority trial of aspirin compared to low molecular weight heparin for venous thromboembolism prophylaxis in hip or knee arthroplasty, a registry nested study) aims to determine whether aspirin is non-inferior to low molecular weight heparin (LMWH) in preventing symptomatic venous thromboembolism (VTE) following hip arthroplasty (HA) or knee arthroplasty (KA). The study is nested within the Australian Orthopaedic Association National Joint Replacement Registry. The trial was commenced in April 2019 and after an unplanned interim analysis, recruitment was stopped (December 2020), as the stopping rule was met for the primary outcome. The clusters comprised hospitals performing > 250 HA and/or KA procedures per annum, whereby all adults (> 18 years) undergoing HA or KA were recruited. Each hospital was randomised to commence with aspirin, orally, 85-150 mg daily or LMWH (enoxaparin), 40 mg, subcutaneously, daily within 24 h postoperatively, for 35 days after HA and 14 days after KA. Crossover was planned once the registration target was met for the first arm. The primary end point is symptomatic VTE within 90 days. Secondary outcomes include readmission, reoperation, major bleeding and death within 90 days, and reoperation and patient-reported pain, function and health status at 6 months. The main analyses will focus on the primary and secondary outcomes for patients undergoing elective primary total HA and KA for osteoarthritis. The analysis will use an intention-to-treat approach with cluster summary methods to compare treatment arms. As the trial stopped early, analyses will account for incomplete cluster crossover and unequal cluster sizes. CONCLUSIONS This paper provides a detailed statistical analysis plan for CRISTAL. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry ACTRN12618001879257 . Registered on 19/11/2018.
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Affiliation(s)
- Verinder Singh Sidhu
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, South West Sydney Clinical School, The University of New South Wales Sydney, Sydney, NSW, Australia.
| | - Thu-Lan Kelly
- Clinical and Health Sciences, Quality Use of Medicines Pharmacy Research Centre, University of South Australia, Adelaide, Australia
| | - Nicole Pratt
- Clinical and Health Sciences, Quality Use of Medicines Pharmacy Research Centre, University of South Australia, Adelaide, Australia
| | - Steven Graves
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia
| | - Justine Naylor
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, South West Sydney Clinical School, The University of New South Wales Sydney, Sydney, NSW, Australia
| | - Richard de Steiger
- Department of Surgery, Epworth Healthcare, University of Melbourne, Melbourne, Victoria, Australia
| | - Ilana Ackerman
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Sam Adie
- St. George and Sutherland Clinical School, The University of New South Wales Sydney, Sydney, NSW, Australia
| | - Michelle Lorimer
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Durga Bastiras
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Kara Cashman
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Ian Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, South West Sydney Clinical School, The University of New South Wales Sydney, Sydney, NSW, Australia.,Institute of Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia
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Lieberman JR, Bell JA. Venous Thromboembolic Prophylaxis After Total Hip and Knee Arthroplasty. J Bone Joint Surg Am 2021; 103:1556-1564. [PMID: 34133395 DOI: 10.2106/jbjs.20.02250] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ The selection of an agent for prophylaxis against venous thromboembolism (VTE) is a balance between efficacy and safety. The goal is to prevent symptomatic VTE while limiting the risk of bleeding. ➤ The optimal agent for VTE prophylaxis has not been identified. The American College of Chest Physicians guidelines recommend that, after total hip or total knee arthroplasty, patients receive at least 10 to 14 days of 1 of the following prophylaxis agents: aspirin, adjusted-dose vitamin K antagonist, apixaban, dabigatran, fondaparinux, low-molecular-weight heparin, low-dose unfractionated heparin, rivaroxaban, or portable home mechanical compression. ➤ The use of aspirin for VTE prophylaxis has increased in popularity over the past decade because it is effective, and it is an oral agent that does not require monitoring. The true efficacy of aspirin needs to be determined in multicenter randomized clinical trials. ➤ Validated risk stratification protocols are essential to identify the safest and most effective regimen for VTE prophylaxis for individual patients. There is no consensus regarding the optimal method for risk stratification; the selection of a prophylaxis agent should be determined by shared decision-making with the patient to balance the risk of thrombosis versus bleeding. ➤ Patients with atrial fibrillation being treated with chronic warfarin therapy or direct oral anticoagulants should stop the agent 3 to 5 days prior to surgery. Patients do not typically require bridging therapy prior to surgery.
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Affiliation(s)
- Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Morgano GP, Wiercioch W, Anderson DR, Brożek JL, Santesso N, Xie F, Cuker A, Nieuwlaat R, Akl EA, Darzi A, Yepes-Nuñez JJ, Exteandia-Ikobaltzeta I, Rahman M, Rajasekhar A, Rogers F, Tikkinen KAO, Yates AJ, Dahm P, Schünemann HJ. A modeling approach to derive baseline risk estimates for GRADE recommendations:Concepts, development, and results of its application to the American Society of Hematology 2019 guidelines on prevention of venous thromboembolism in surgical hospitalized patients. J Clin Epidemiol 2021; 140:69-78. [PMID: 34284102 DOI: 10.1016/j.jclinepi.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/18/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The goal of this study was to develop an approach that can be used where baseline risk estimates that are directly applicable to prioritized patient-important outcomes are not available from published studies. STUDY DESIGN The McMaster University GRADE Centre and the ASH guideline panel for the prevention of VTE in surgical patients developed a modeling approach based on explicit assumptions about the distribution of symptoms, anatomical location, and severity of VTE events. RESULTS We applied the approach to derive modeled estimates of baseline risk. These estimates were used to calculated absolute measures of anticipated effects that informed the discussion of the evidence and the formulation of 30 guideline recommendations. CONCLUSIONS Our approach can assist guideline developers facing a lack of information about baseline risk estimates that directly apply to outcomes of interest. The use of modeled estimates increases transparency in the process and makes the baseline risk used by guideline experts explicit during their decision-making.
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Affiliation(s)
- Gian Paolo Morgano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | | | - Jan L Brożek
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Nancy Santesso
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, USA
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Lebanon
| | - Andrea Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Juan José Yepes-Nuñez
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada; School of Medicine, Universidad de los Andes, Colombia
| | | | - Maryam Rahman
- Lillian S. Wells Department of Neurosurgery, University of Florida, USA
| | - Anita Rajasekhar
- Division of Hematology and Oncology, Department of Medicine, University of Florida, USA
| | - Frederick Rogers
- Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, USA
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Finland,; Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
| | - Adolph J Yates
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, USA
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, USA; Department of Urology, University of Minnesota, USA
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada; Department of Medicine, McMaster University, Canada.
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Rooney T, Barrack RL, Clohisy JC, Nunley RM, Lawrie CM. Is Apixaban Safe and Effective for Venous Thromboembolism Prophylaxis After Primary Total Hip and Total Knee Arthroplasties? J Arthroplasty 2021; 36:S328-S331. [PMID: 33888386 DOI: 10.1016/j.arth.2021.03.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/07/2021] [Accepted: 03/10/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a serious complication of total hip arthroplasty (THA) and total knee arthroplasty (TKA). Apixaban is approved for VTE prophylaxis. This study seeks to ascertain the risk of VTE and bleeding complications in patients undergoing primary THA and TKA receiving apixaban for postoperative VTE prophylaxis for one of the following indications: high risk for VTE, previously on apixaban, and contraindication to the use of aspirin. METHODS This is a retrospective cohort study of patients who underwent primary THA or TKA over a 17-month period and were prescribed apixaban for thromboprophylaxis postoperatively. RESULTS 230 patients were included in the study, 110 TKA and 120 THA. The primary reasons for high-risk VTE status included personal and family history of VTE, and 13% were taking apixaban preoperatively for atrial fibrillation. 1 patient (0.43%) who underwent TKA had a DVT with PE. 2.6% of patients had wound complications requiring operative treatment, and 0.87% of THA patients underwent revision arthroplasty. CONCLUSION The use of apixaban for VTE prophylaxis after primary THA and TKA in patients at high risk for VTE, in patients previously on apixaban, and in patients with a contraindication to the use of aspirin is associated with a low risk of VTE and bleeding complications.
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Affiliation(s)
- Timothy Rooney
- Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO
| | - Robert L Barrack
- Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO
| | - John C Clohisy
- Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO
| | - Ryan M Nunley
- Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO
| | - Charles M Lawrie
- Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO
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19
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Utilization Patterns, Efficacy, and Complications of Venous Thromboembolism Prophylaxis Strategies in Revision Hip and Knee Arthroplasty as Reported by American Board of Orthopaedic Surgery Part II Candidates. J Arthroplasty 2021; 36:2364-2370. [PMID: 33674164 DOI: 10.1016/j.arth.2021.01.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/18/2021] [Accepted: 01/26/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The optimum venous thromboembolism (VTE) prophylaxis strategy to minimize risk of VTE and bleeding complications following revision total hip and knee arthroplasty (rTHA/rTKA) is controversial. The purpose of this study is to describe current VTE prophylaxis patterns following revision arthroplasty procedures to determine efficacy, complication rates, and prescribing patterns for different prophylactic strategies. METHODS The American Board of Orthopaedic Surgery Part II (oral) examination case list database was analyzed. Current Procedural Terminology codes for rTHA/rTKA were queried and geographic region, VTE prophylaxis strategy, and complications were obtained. Less aggressive prophylaxis patterns were defined if only aspirin and/or sequential compression devises were utilized. More aggressive VTE prophylaxis patterns were considered if any of low-molecular-weight heparin (enoxaparin), warfarin, rivaroxaban, fondaparinux, or other strategies were used. RESULTS In total, 6387 revision arthroplasties were included. The national rate of less aggressive VTE prophylaxis strategies was 35.3% and more aggressive in 64.7%. Use of less aggressive prophylaxis strategy was significantly associated with patients having no complications (89.8% vs 81.9%, P < .001). Use of more aggressive prophylaxis patterns was associated with higher likelihood of mild thrombotic (1.2% vs 0.3%, P < .001), mild bleeding (1.7% vs 0.6%, P < .001), moderate thrombotic (2.6% vs 0.4%, P < .001), moderate bleeding (6.2% vs 4.0%, P < .001), severe bleeding events (4.4% vs 2.4%, P < .001), infections (6.4% vs 3.8%, P < .001), and death within 90 days (3.1% vs 1.3%, P < .001). There were no significant differences in rates of fatal pulmonary embolism (0.1% vs 0.04%, P = .474). Subgroup analysis of rTHA and rTKA patients showed similar results. CONCLUSION The individual rationale for using a more aggressive VTE prophylaxis strategy was unknown; however, more aggressive strategies were associated with higher rates of bleeding and thrombotic complications. Less aggressive strategies were not associated with a higher rate of thrombosis. LEVEL OF EVIDENCE Therapeutic Level III.
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Aspirin versus enoxaparin for the initial prevention of venous thromboembolism following elective arthroplasty of the hip or knee: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2021; 107:102606. [PMID: 32631716 DOI: 10.1016/j.otsr.2020.04.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Aspirin is perceived to be non-inferior to enoxaparin, a low-molecular-weight heparin, for the prevention of venous thromboembolism (VTE) following elective arthroplasty of the hip or knee and is recommended in clinical guidelines internationally. Previous systematic reviews of aspirin as VTE prophylaxis have been limited by the inclusion of heterogenous studies where aspirin is commenced after the initial high-risk postoperative period. The purpose of this systematic review and meta-analysis was to compare the efficacy and associated harms of aspirin and enoxaparin when used as VTE prophylaxis in the initial postoperative period following elective arthroplasty of the hip or knee. We sought to: (1) to compare the use of aspirin versus enoxaparin following elective joint replacement of the hip or knee on the primary outcomes of incidence of VTE and mortality up to 3 months postoperatively and (2) assess the efficacy of aspirin with respect to secondary outcomes such as major or minor bleeding events. We hypothesised that aspirin would have equivalent efficacy for the prevention of VTE when used as initial prophylactic agent, without increasing harm from bleeding events. PATIENTS AND METHODS We searched Pubmed, Embase, Medline and Cochrane Central for randomized controlled trials reporting the primary outcomes of VTE incidence and mortality. Secondary outcomes included major (compromise of organ, limb or muscle function requiring unplanned re-operation) and minor bleeding events (wound ooze, minor bleed, infection). Included trials underwent a risk of bias and quality of evidence assessment using the GRADE criteria. RESULTS Four trials involving 1507 participants who underwent elective lower limb arthroplasty were included. We did not detect a significant difference in overall VTE rates when comparing aspirin versus enoxaparin (RR, 0.84; 95% CI: 0.41 to 1.75; p=0.65). Mortality was reported by one study and no events were recorded. There were no significant differences in the rates of all major (RR, 0.84; 95% CI: 0.08 to 9.16) or minor (RR, 0.77; 95% CI: 0.34 to 1.72) bleeding events between the aspirin and enoxaparin groups. Included trials demonstrated a significant risk of bias, and Low to Very Low quality of evidence for primary outcomes, and Moderate to Very Low for secondary outcomes. CONCLUSION There is currently a lack of high quality randomised controlled trials supporting the use of aspirin as VTE chemoprophylaxis in the initial postoperative period for both total hip and total knee arthroplasty. The results of this meta-analysis provide cautious endorsement for the position that aspirin is likely a safe alternative to enoxaparin for TKA patients as part of a multimodal enhanced recovery protocol, but care is advised for THA patients owing to a lack of data from trials. Current evidence from randomized controlled trials is generally of low quality, and does not estimate critical event data for VTE incidence or mortality, as well as major and minor bleeding events with sufficient certainty. PROSPERO Registration CRD42018110784. LEVEL OF EVIDENCE II, systematic review.
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21
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Peng HM, Chen X, Wang YO, Bian YY, Feng B, Wang W, Weng XS, Qian WW. Risk-Stratified Venous Thromboembolism Prophylaxis after Total Joint Arthroplasty: Low Molecular Weight Heparins and Sequential Aspirin vs Aggressive Chemoprophylaxis. Orthop Surg 2021; 13:260-266. [PMID: 33448672 PMCID: PMC7862181 DOI: 10.1111/os.12926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 12/03/2020] [Accepted: 12/20/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a significant concern post total joint arthroplasty (TJA). However, the optimal prevention method of VTE remains controversial at present. This study aims to evaluate a risk-stratified VTE prophylaxis protocol for patients undergoing TJA. METHODS A total of 891 TJA patients from January 2011 to November 2019 were retrospectively investigated. The study was divided into two cohorts. In cohort 1, 410 patients (250 females and 160 males, mean age 64.32 years) were treated with an aggressive VTE chemoprophylaxis protocol. In cohort 2, 481 patients were treated with a risk-stratified protocol that utilized low molecular weight heparins (LMWH) and sequential aspirin (ASA) for standard-risk patients (a total of 288 containing 177 females and 111 males, mean age 65.4 years), and targeted anticoagulation for high-risk patients (a total of 193 containing 121 females and 72 males, mean age 66.8 years). The patients were followed up at 2-4 weeks for an initial visit and at 6-10 weeks for a subsequent visit after surgery. A chart review of all patient medical records was performed to record the demographics, comorbidities, deep vein thrombosis, pulmonary embolus, superficial infection, deep infection, bleeding complications, and 90-day readmissions. RESULTS The VTE rate was 1.71% (7/410) in cohort 1 and 1.46% (7/481) in cohort 2 respectively. For cohort 2, the VTE rate was 2.07% (4/193) in high-risk group and 1.04% (3/288) in standard-risk group. The readmission rate was 2.44% (10/410) in cohort 1 and 2.08% (10/481) in cohort 2. For cohort 2, the readmission rate was 2.07% (4/193) in high-risk group and 2.08% (6/288) in standard-risk group. The reasons for readmission were as follows: infection, 1.3% (5/410) in cohort 1 and 1.3% (6/481) in cohort 2; wound or bleeding complications, 0.48% (2/410) in cohort 1 and 0.2% (1/481) in cohort 2; trauma, 0.2% (1/410) in cohort 1 and 0.2% (1/481) in cohort 2; VTE, 0.2% (1/410) in cohort 1 and 0.2% (1/481) in cohort 2; others, 0.2% (1/410) in cohort 1 and 0.6% (3/481) in cohort 2. There was a decrease in VTE events and readmissions in the risk-stratified cohort, although this did not reach statistical significance. However, it was found that there was a significant reduction in costs (P < 0.001) with the use of LMWH/ASA, when compared with aggressive anticoagulation agents in the risk-stratified cohort. CONCLUSION The use of LMWH/ASA in a risk-stratified TJA population is a safe and cost-effective method of VTE prophylaxis.
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Affiliation(s)
- Hui-Ming Peng
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
| | - Xi Chen
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
| | - Yi-Ou Wang
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
| | - Yan-Yan Bian
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
| | - Bin Feng
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
| | - Wei Wang
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
| | - Xi-Sheng Weng
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
| | - Wen-Wei Qian
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
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Hood B, Springer B, Odum S, Curtin BM. No difference in patient compliance between full-strength versus low-dose aspirin for VTE prophylaxis following total hip and total knee replacement. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:779-783. [PMID: 33211234 DOI: 10.1007/s00590-020-02833-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 11/10/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The utilization of aspirin for VTE prophylaxis following TJA has increased due to updated clinical practice guidelines. Aspirin is the only approved VTE prophylaxis medication that does not require a prescription, but adherence and tolerance remain unknown. We hypothesized decreased patient compliance utilizing full-strength 325 mg aspirin twice daily following TJA when compared to low-dose 81 mg twice daily. We also investigated the reasons why patients may elect to stop the medication earlier than 28 days. METHODS A consecutive series of patients undergoing primary total hip or knee arthroplasty utilizing 325 or 81 mg of EC aspirin twice daily for 4 weeks were surveyed to determine compliance with use and any adverse events related to the medication. Fisher's exact test was used to determine statistical significance. RESULTS 404 patients were enrolled with 199 patients prescribed the 325 mg regimen. Fifty-two patients who were prescribed 325 mg missed a dose versus 51 patients who were prescribed 81 mg (p = 0.082). No significant difference in the frequency of missed doses (missing < 5 doses, 5-10 doses, > 10 doses) between the treatment regimens (p = 0.78, 0.39 and 0.83, respectively). Most commonly cited reason for stopping aspirin in both treatment groups was gastrointestinal issues (10.5% and 7%, respectively). DISCUSSION AND CONCLUSIONS By surveying patients on their use of aspirin we find no difference in adherence between full-strength and low-dose treatment regimens. Additionally, we have a better understanding of the reasons for noncompliance as GI upset was a relatively common complaint with both doses.
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Affiliation(s)
- Brandon Hood
- OrthoCarolina Hip and Knee Center, 2001 Vail Avenue, Ste 200A, Charlotte, NC, 28207, USA
| | - Bryan Springer
- OrthoCarolina Hip and Knee Center, 2001 Vail Avenue, Ste 200A, Charlotte, NC, 28207, USA
| | - Susan Odum
- Odum OrthoCarolina Research Institute, 2001 Vail Avenue, Charlotte, NC, 28207, USA
| | - Brian M Curtin
- OrthoCarolina Hip and Knee Center, 2001 Vail Avenue, Ste 200A, Charlotte, NC, 28207, USA.
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Matharu GS, Garriga C, Whitehouse MR, Rangan A, Judge A. Is Aspirin as Effective as the Newer Direct Oral Anticoagulants for Venous Thromboembolism Prophylaxis After Total Hip and Knee Arthroplasty? An Analysis From the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man. J Arthroplasty 2020; 35:2631-2639.e6. [PMID: 32532481 DOI: 10.1016/j.arth.2020.04.088] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/22/2020] [Accepted: 04/26/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Few studies have compared aspirin with direct oral anticoagulants (DOACs) (DOACs = direct thrombin inhibitors and factor Xa inhibitors) for venous thromboembolism (VTE) prophylaxis after total hip arthroplasty (THA) and total knee arthroplasty (TKA). We assessed the efficacy and safety of aspirin compared with DOACs for VTE prophylaxis after THA and TKA using the world's largest joint arthroplasty registry. METHODS We studied the National Joint Registry linked to English hospital inpatient episodes for 218,650 THA and TKA patients. Patients receiving aspirin were matched separately to patients receiving direct thrombin inhibitors and factor Xa inhibitors using propensity scores. Outcomes assessed at 90 days included VTE, length of stay, and adverse events. RESULTS After THA, there was a significantly lower risk of VTE associated with the use of direct thrombin inhibitors (0.44%; odds ratio [OR], 0.69; 95% confidence interval [95% CI], 0.55-0.87; P = .002) and factor Xa inhibitors (0.37%; OR, 0.63; 95% CI, 0.47-0.85; P = .003) compared with aspirin (0.63%). After THA, direct thrombin inhibitors (coefficient, -0.37 days; 95% CI, -0.43 to -0.31; P < .001) and factor Xa inhibitors (coefficient, -0.80 days; 95% CI, -0.87 to -0.74; P < .001) were associated with a reduced length of stay compared with aspirin. Similar findings for both outcomes were observed after TKA. Compared with aspirin, DOACs were not associated with an increase in the risk of short-term revision surgery, reoperation, major hemorrhage, wound disruption, surgical site infection, and mortality. CONCLUSION After THA and TKA, DOACs were associated with a reduced risk of VTE compared with aspirin. DOACs were associated with a reduced length of stay, and DOACs were not associated with an increase in the risk of further surgery, wound problems, bleeding complications, or mortality compared with aspirin.
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Affiliation(s)
- Gulraj S Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Department of Translational Health Sciences, Musculoskeletal Research Unit, University of Bristol, Bristol, United Kingdom
| | - Cesar Garriga
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Centre for Statistics in Medicine, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom
| | - Michael R Whitehouse
- Department of Translational Health Sciences, Musculoskeletal Research Unit, University of Bristol, Bristol, United Kingdom
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man; Department of Health Sciences, University of York, Heslington, York, United Kingdom
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Department of Translational Health Sciences, Musculoskeletal Research Unit, University of Bristol, Bristol, United Kingdom
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Ní Cheallaigh S, Fleming A, Dahly D, Kehoe E, O'Byrne JM, McGrath B, O'Connell C, Sahm LJ. Aspirin compared to enoxaparin or rivaroxaban for thromboprophylaxis following hip and knee replacement. Int J Clin Pharm 2020; 42:853-860. [PMID: 32328957 DOI: 10.1007/s11096-020-01032-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/08/2020] [Indexed: 11/29/2022]
Abstract
Background The risk of venous thromboembolism following major orthopaedic surgery is among the highest for all surgical specialties. Our hospital guidelines for thromboprophylaxis following elective primary total hip or knee replacement are based on American College of Chest Physicians guidance. The most recent change to local guidelines was the introduction of the extended aspirin regimen as standard thromboprophylaxis. Objective To establish the appropriateness of this regimen by comparing venous thromboembolism rates in patients receiving extended aspirin to previous regimens. Setting The largest dedicated orthopaedic hospital in Ireland. Methods This was a retrospective cohort study. Data were collected from patient record software. All eligible patients undergoing primary total hip or knee replacement between 1st January 2010 and 30th June 2016 were included. Main outcome measure Venous thromboembolism up to 6 months post-operatively. Results Of the 6548 participants (55.3% female, mean age 65.4 years (± 11.8 years, 55.8% underwent total hip replacement), venous thromboembolism occurred in 65 (0.99%). Venous thromboembolism rate in both the inpatient enoxaparin group (n = 961) and extended aspirin group (n = 3460) was 1.04% and was 0.66% in the modified rivaroxaban group (n = 1212). Non-inferiority analysis showed the extended aspirin regimen to be equivalent to the modified rivaroxaban regimen. History of venous thromboembolism was the only significant demographic risk factor for post-operative venous thromboembolism (0.87% vs. 3.54%, p = 0.0002). Conclusion In daily clinical practice, extended aspirin regimen is at least as effective as modified rivaroxaban for preventing clinically important venous thromboembolism among patients undergoing hip or knee arthroplasty who are discharged from the hospital without complications. Aspirin can be considered a safe and effective agent in the prevention of venous thromboembolism after total hip or total knee replacement.
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Affiliation(s)
| | - Aoife Fleming
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | - Darren Dahly
- HRB Clinical Research Facility Cork, School of Public Health, University College Cork, Cork, Ireland
| | - Eimear Kehoe
- Pharmacy Department, Cappagh National Orthopaedic Hospital, Dublin 11, Ireland
| | - John M O'Byrne
- RCSI Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital, Dublin 11, Ireland
| | - Brid McGrath
- Department of Anaesthetics, Cappagh National Orthopaedic Hospital, Dublin 11, Ireland
| | - Charles O'Connell
- Pharmacy Department, Cappagh National Orthopaedic Hospital, Dublin 11, Ireland
| | - Laura J Sahm
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland.
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Azboy I, Groff H, Goswami K, Vahedian M, Parvizi J. Low-Dose Aspirin Is Adequate for Venous Thromboembolism Prevention Following Total Joint Arthroplasty: A Systematic Review. J Arthroplasty 2020; 35:886-892. [PMID: 31733981 DOI: 10.1016/j.arth.2019.09.043] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/09/2019] [Accepted: 09/26/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patients undergoing total joint arthroplasty (TJA) are at risk of developing venous thromboembolism (VTE) without adequate prophylaxis. Since the American Academy of Orthopedic Surgeons issued guidelines in 2007 recommending aspirin 325 mg bis in die for 6 weeks, aspirin has been favored as the main VTE prophylaxis. However, the appropriate dose and duration of aspirin are not well-studied. This systematic review aims to identify any differences between high and low dose as well as duration for aspirin thromboprophylaxis after TJA as outlined by previous studies. METHODS A search was performed using Ovid MEDLINE, EMBASE, and PubMed, including articles up to July 2016. Studies were included if they contained at least 1 cohort that underwent TJA with aspirin as the sole chemoprophylaxis and reported either (1) symptomatic VTE or (2) secondary outcomes such as major bleeding or 90-day mortality. RESULTS Forty-five papers were included. There were no significant differences in symptomatic pulmonary embolism, symptomatic deep vein thrombosis, 90-day mortality, or major bleeding between patients receiving low-dose or high-dose aspirin. Patients treated with aspirin for <4 weeks had a higher risk of major bleeding (1.59%) vs patients treated for 4 weeks (0.15%), which may be attributed to premature cessation or differential reporting. Patients treated with aspirin for <4 weeks had a statistically higher 90-day mortality (1.95%) vs patients treated for 4 weeks (0.07%). There was no significant difference between incidence of pulmonary embolism or deep vein thrombosis and the durations of aspirin treatment. CONCLUSION This review suggests that low-dose aspirin is not inferior to high-dose aspirin for VTE thromboprophylaxis in TJA patients. Additionally, patients treated with aspirin for less than 4 weeks may have a higher risk of major bleeding and 90-day mortality compared to patients treated for a longer duration.
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Affiliation(s)
- Ibrahim Azboy
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Department of Orthopaedics and Traumatology, Istanbul Medipol University School of Medicine, Istanbul, Turkey
| | - Hannah Groff
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Karan Goswami
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Mohammed Vahedian
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Matharu GS, Kunutsor SK, Judge A, Blom AW, Whitehouse MR. Clinical Effectiveness and Safety of Aspirin for Venous Thromboembolism Prophylaxis After Total Hip and Knee Replacement: A Systematic Review and Meta-analysis of Randomized Clinical Trials. JAMA Intern Med 2020; 180:376-384. [PMID: 32011647 PMCID: PMC7042877 DOI: 10.1001/jamainternmed.2019.6108] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Patients undergoing total hip replacement (THR) and total knee replacement (TKR) receive venous thromboembolism (VTE) pharmacoprophylaxis. It is unclear which anticoagulant is preferable. Observational data suggest aspirin provides effective VTE prophylaxis. OBJECTIVE To assess the effectiveness and safety of aspirin for VTE prophylaxis after THR and TKR. DATA SOURCES A systematic review and meta-analysis was performed of randomized clinical trials (RCTs), with no language restrictions, from inception to September 19, 2019, using MEDLINE, Embase, Web of Science, Cochrane Library, and bibliographic searches. The computer-based searches combined terms and combinations of keywords related to the population (eg, hip replacement, knee replacement, hip arthroplasty, and knee arthroplasty), drug intervention (eg, aspirin, heparin, clexane, dabigatran, rivaroxaban, and warfarin), and outcome (eg, venous thromboembolism, deep vein thrombosis, pulmonary embolism, and bleeding) in humans. STUDY SELECTION This study included RCTs assessing the effectiveness and safety of aspirin for VTE prophylaxis compared with other anticoagulants in adults undergoing THR and TKR. The RCTs with a placebo control group were excluded. The searches and study selection were independently performed. DATA EXTRACTION AND SYNTHESIS This study followed PRISMA recommendations and used the Cochrane Collaboration's risk of bias tool. Data were screened and extracted independently by both reviewers. Study-specific relative risks (RRs) were aggregated using random-effects models. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. MAIN OUTCOMES AND MEASURES The primary outcome was any postoperative VTE (asymptomatic or symptomatic). Secondary outcomes were adverse events associated with therapy, including bleeding. RESULTS Of 437 identified articles, 13 RCTs were included (6060 participants; 3466 [57.2%] women; mean age, 63.0 years). The RR of VTE after THR and TKR was 1.12 (95% CI, 0.78-1.62) for aspirin compared with other anticoagulants. Comparable findings were observed for deep vein thrombosis (DVT) (RR, 1.04; 95% CI, 0.72-1.51) and pulmonary embolism (PE) (RR, 1.01; 95% CI, 0.68-1.48). The risk of adverse events, including major bleeding, wound hematoma, and wound infection, was not statistically significantly different in patients receiving aspirin vs other anticoagulants. When analyzing THRs and TKRs separately, there was no statistically significant difference in the risk of VTE, DVT, and PE between aspirin and other anticoagulants. Aspirin had a VTE risk not statistically significantly different from low-molecular-weight heparin (RR, 0.76; 95% CI, 0.37-1.56) or rivaroxaban (RR, 1.52; 95% CI, 0.56-4.12). The quality of the evidence ranged from low to high. CONCLUSIONS AND RELEVANCE In terms of clinical effectiveness and safety profile, aspirin did not differ statistically significantly from other anticoagulants used for VTE prophylaxis after THR and TKR. Future trials should focus on noninferiority analysis of aspirin compared with alternative anticoagulants and cost-effectiveness.
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Affiliation(s)
- Gulraj S Matharu
- Musculoskeletal Research Unit, Bristol Medical School, Southmead Hospital, University of Bristol, Bristol, United Kingdom
| | - Setor K Kunutsor
- Musculoskeletal Research Unit, Bristol Medical School, Southmead Hospital, University of Bristol, Bristol, United Kingdom.,National Institute for Health Research Bristol Biomedical Research Centre, Bristol, United Kingdom
| | - Andrew Judge
- Musculoskeletal Research Unit, Bristol Medical School, Southmead Hospital, University of Bristol, Bristol, United Kingdom.,National Institute for Health Research Bristol Biomedical Research Centre, Bristol, United Kingdom
| | - Ashley W Blom
- Musculoskeletal Research Unit, Bristol Medical School, Southmead Hospital, University of Bristol, Bristol, United Kingdom.,National Institute for Health Research Bristol Biomedical Research Centre, Bristol, United Kingdom
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Bristol Medical School, Southmead Hospital, University of Bristol, Bristol, United Kingdom.,National Institute for Health Research Bristol Biomedical Research Centre, Bristol, United Kingdom
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Anderson DR, Morgano GP, Bennett C, Dentali F, Francis CW, Garcia DA, Kahn SR, Rahman M, Rajasekhar A, Rogers FB, Smythe MA, Tikkinen KAO, Yates AJ, Baldeh T, Balduzzi S, Brożek JL, Ikobaltzeta IE, Johal H, Neumann I, Wiercioch W, Yepes-Nuñez JJ, Schünemann HJ, Dahm P. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Adv 2019; 3:3898-3944. [PMID: 31794602 PMCID: PMC6963238 DOI: 10.1182/bloodadvances.2019000975] [Citation(s) in RCA: 284] [Impact Index Per Article: 56.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/22/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common source of perioperative morbidity and mortality. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about preventing VTE in patients undergoing surgery. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic reviews. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 30 recommendations, including for major surgery in general (n = 8), orthopedic surgery (n = 7), major general surgery (n = 3), major neurosurgical procedures (n = 2), urological surgery (n = 4), cardiac surgery and major vascular surgery (n = 2), major trauma (n = 2), and major gynecological surgery (n = 2). CONCLUSIONS For patients undergoing major surgery in general, the panel made conditional recommendations for mechanical prophylaxis over no prophylaxis, for pneumatic compression prophylaxis over graduated compression stockings, and against inferior vena cava filters. In patients undergoing total hip or total knee arthroplasty, conditional recommendations included using either aspirin or anticoagulants, as well as for a direct oral anticoagulant over low-molecular-weight heparin (LMWH). For major general surgery, the panel suggested pharmacological prophylaxis over no prophylaxis, using LMWH or unfractionated heparin. For major neurosurgery, transurethral resection of the prostate, or radical prostatectomy, the panel suggested against pharmacological prophylaxis. For major trauma surgery or major gynecological surgery, the panel suggested pharmacological prophylaxis over no prophylaxis.
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Affiliation(s)
- David R Anderson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Charles W Francis
- Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - David A Garcia
- Division of Hematology, Department of Medicine, University of Washington Medical Center, University of Washington School of Medicine, Seattle, WA
| | - Susan R Kahn
- Department of Medicine, McGill University and Lady Davis Institute, Montreal, QC, Canada
| | | | - Anita Rajasekhar
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL
| | - Frederick B Rogers
- Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, PA
| | - Maureen A Smythe
- Department of Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI
- Department of Pharmacy Practice, Wayne State University, Detroit, MI
| | - Kari A O Tikkinen
- Department of Urology and
- Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Adolph J Yates
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tejan Baldeh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sara Balduzzi
- Department of Diagnostic, Clinical, and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Jan L Brożek
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | | | - Herman Johal
- Center for Evidence-Based Orthopaedics, Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Ignacio Neumann
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, MN; and
- Department of Urology, University of Minnesota, Minneapolis, MN
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Sidhu VS, Graves SE, Buchbinder R, Naylor JM, Pratt NL, de Steiger RS, Chong BH, Ackerman IN, Adie S, Harris A, Hansen A, Cripps M, Lorimer M, Webb S, Clavisi O, Griffith EC, Anandan D, O'Donohue G, Kelly TL, Harris IA. CRISTAL: protocol for a cluster randomised, crossover, non-inferiority trial of aspirin compared to low molecular weight heparin for venous thromboembolism prophylaxis in hip or knee arthroplasty, a registry nested study. BMJ Open 2019; 9:e031657. [PMID: 31699735 PMCID: PMC6858170 DOI: 10.1136/bmjopen-2019-031657] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a serious complication following hip arthroplasty (HA) and knee arthroplasty (KA). This study aims to determine whether aspirin is non-inferior to low molecular weight heparin (LMWH) in preventing symptomatic VTE following HA and KA. METHODS AND ANALYSIS This is a cluster randomised, crossover, non-inferiority, trial nested within the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). The clusters will consist of Australian hospitals performing at least 250 HA and/or KA procedures per annum. All adult patients undergoing HA or KA will be included. The intervention will be aspirin, orally, 85-150 mg daily. The comparator will be LMWH (enoxaparin) 40 mg, subcutaneously, daily. Both drugs will commence within 24 hours postoperatively and continue for 35 days after HA and 14 days after KA. Each hospital will be randomised to commence with aspirin or LMWH and then crossover to the alternative treatment after meeting the recruitment target. Data will be collected through the AOANJRR via patient-reported surveys. The primary outcome is symptomatic VTE within 90 days post surgery, verified by AOANJRR staff. The primary analysis will include only patients undergoing elective primary total hip arthroplasty and total knee arthroplasty for osteoarthritis. Secondary outcomes will include symptomatic VTE for all HA and KA (including partial and revision) within 90 days, readmission, reoperation, major bleeding and death within 90 days and reoperation, death and patient-reported pain, function and health status at 6 months. If aspirin is found to be inferior, a cost-effectiveness analysis will be conducted. The study will aim to recruit 15 562 patients from 31 hospitals. ETHICS AND DISSEMINATION Ethics approval has been granted. Trial results will be submitted for publication. The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12618001879257, pre-results) and is endorsed by the Australia and New Zealand Musculoskeletal Clinical Trials Network.
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Affiliation(s)
- Verinder Singh Sidhu
- CRISTAL Study Group, Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
| | - Steven E Graves
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia
| | - Justine Maree Naylor
- CRISTAL Study Group, Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
| | - Nicole L Pratt
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Richard S de Steiger
- Department of Surgery, Epworth Healthcare, University of Melbourne, Melbourne, Victoria, Australia
| | - Beng H Chong
- Department of Haematology, Saint George and Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Ilana N Ackerman
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Sam Adie
- Faculty of Medicine, Saint George and Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Anthony Harris
- Monash University Centre for Health Economics, Caufield, Victoria, Australia
| | - Amber Hansen
- CRISTAL Study Group, Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
| | - Maggie Cripps
- CRISTAL Study Group, Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
| | - Michelle Lorimer
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Steve Webb
- Department of Intensive Care, St John of God Hospital, Subiaco, Western Australia, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Austria
| | | | - Elizabeth C Griffith
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Durga Anandan
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Grace O'Donohue
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Thu-Lan Kelly
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Ian A Harris
- CRISTAL Study Group, Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney School of Public Health, Sydney, New South Wales, Australia
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Harris IA, Sidhu V. Aspirin as venous thromboembolic event prophylaxis post total hip and knee arthroplasty. ANZ J Surg 2019; 89:1184-1185. [PMID: 31621169 DOI: 10.1111/ans.15420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 07/11/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Ian A Harris
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Verinder Sidhu
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
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Lewis S, Glen J, Dawoud D, Dias S, Cobb J, Griffin X, Reed M, Sharpin C, Stansby G, Barry P. Venous Thromboembolism Prophylaxis Strategies for People Undergoing Elective Total Hip Replacement: A Systematic Review and Network Meta-Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:953-969. [PMID: 31426937 DOI: 10.1016/j.jval.2019.02.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 12/22/2018] [Accepted: 02/19/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To assess the efficacy and safety of venous thromboembolism prophylaxis in people undergoing elective total hip replacement. METHODS Systematic review and Bayesian network meta-analyses of randomized controlled trials were conducted for 3 outcomes: deep vein thrombosis (DVT), pulmonary embolism (PE), and major bleeding (MB). MEDLINE, EMBASE, and Cochrane Library (CENTRAL) databases were searched. Study quality was assessed using the Cochrane risk-of-bias checklist. Fixed- and random-effects models were fitted and compared. The median relative risk (RR) and odds ratio (OR) compared with no prophylaxis, with their 95% credible intervals (CrIs), rank, and probability of being the best, were calculated. RESULTS Forty-two (n = 24 374, 26 interventions), 30 (n = 28 842, 23 interventions), and 24 (n = 31 792, 15 interventions) randomized controlled trials were included in the DVT, PE, and MB networks, respectively. Rivaroxaban had the highest probability of being the most effective intervention for DVT (RR 0.06 [95% CrI 0.01-0.29]). Strategy of low-molecular-weight heparin followed by aspirin had the highest probability of reducing the risk of PE and MB (RR 0.0011 [95% CrI 0.00-0.096] and OR 0.37 [95% CrI 0.00-26.96], respectively). The ranking of efficacy estimates across the 3 networks, particularly PE and MB, had very wide CrIs, indicating high degree of uncertainty. CONCLUSIONS A strategy of low-molecular-weight heparin given for 10 days followed by aspirin for 28 days had the best benefit-risk balance, with the highest probability of being the best on the basis of the results of the PE and MB network meta-analyses. Nevertheless, there is considerable uncertainty around the median ranks of the interventions.
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Affiliation(s)
- Sedina Lewis
- National Guideline Centre, Royal College of Physicians, London, UK
| | - Jessica Glen
- National Guideline Centre, Royal College of Physicians, London, UK
| | - Dalia Dawoud
- Clinical Pharmacy Department, Faculty of Pharmacy, Cairo University, Cairo, Egypt; School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK.
| | | | - Jill Cobb
- National Guideline Centre, Royal College of Physicians, London, UK
| | - Xavier Griffin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Michael Reed
- Northumbria Healthcare NHS Foundation Trust, Northumbria, UK
| | - Carlos Sharpin
- National Guideline Centre, Royal College of Physicians, London, UK
| | - Gerard Stansby
- Newcastle University and Freeman Hospital, Newcastle upon Tyne, UK
| | - Peter Barry
- University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK
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Runner RP, Gottschalk MB, Staley CA, Pour AE, Roberson JR. Utilization Patterns, Efficacy, and Complications of Venous Thromboembolism Prophylaxis Strategies in Primary Hip and Knee Arthroplasty as Reported by American Board of Orthopedic Surgery Part II Candidates. J Arthroplasty 2019; 34:729-734. [PMID: 30685257 DOI: 10.1016/j.arth.2018.12.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/19/2018] [Accepted: 12/12/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Many strategies for venous thromboembolism (VTE) prophylaxis following hip and knee arthroplasty exist, with extensive controversy regarding the optimum strategy to minimize risk of VTE and bleeding complications. Data from the American Board of Orthopedic Surgery Part II (oral) Examination case list database was analyzed to determine efficacy, complication rates, and prescribing patterns for different prophylactic strategies. METHODS The American Board of Orthopedic Surgery case database was queried utilizing Current Procedural Terminology codes 27447 and 27130 for primary total knee and hip arthroplasty, respectively. Geographic region, patient age, gender, deep vein thrombosis prophylaxis strategy, and complications were obtained. Less aggressive prophylaxis patterns were considered if only aspirin and/or sequential compression devises were utilized. More aggressive VTE prophylaxis patterns were considered if any of low-molecular-weight heparin (enoxaparin), warfarin, rivaroxaban, fondaparinux, or other strategies was used. RESULTS In total, 22,072 cases of primary joint arthroplasty were analyzed from 2014 to 2016. The national rate of less aggressive VTE prophylaxis strategies was 45.4%, while more aggressive strategies were used in 54.6% of patients. Significant regional differences in prophylactic strategy patterns exist between the 6 regions. The predominant less aggressive prophylaxis pattern was aspirin with sequential compression devises at 84.8% with 14.8% receiving aspirin alone. Use of less aggressive prophylaxis strategy was significantly associated with patients having no complications (95.5% vs 93.0%). Use of more aggressive prophylaxis patterns was associated with higher likelihood of mild thrombotic (0.9% vs 0.2%), mild bleeding (1.3% vs 0.4%), moderate thrombotic (1.2% vs 0.4%), moderate bleeding (2.7% vs 2.1%), severe thrombotic (0.1% vs 0.0%), severe bleeding events (1.2% vs 0.9%), infections (1.9% vs 1.3%), and death within 90 days (0.7% vs 0.3%). Similar results were found in subgroup analysis of total hip and knee arthroplasty patients. CONCLUSION It was not possible to ascertain the individual rationale for use of more aggressive VTE prophylaxis strategies; however, more aggressive strategies were associated with higher rates of bleeding and thrombotic complications. Less aggressive strategies were not associated with a higher rate of thrombosis. LEVEL OF EVIDENCE Therapeutic Level III. DISCLAIMER All views expressed in the study are the sole views of the authors and do not represent the views of the American Board of Orthopedic Surgery.
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Affiliation(s)
| | | | | | - Aidin E Pour
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI
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Rondon AJ, Shohat N, Tan TL, Goswami K, Huang RC, Parvizi J. The Use of Aspirin for Prophylaxis Against Venous Thromboembolism Decreases Mortality Following Primary Total Joint Arthroplasty. J Bone Joint Surg Am 2019; 101:504-513. [PMID: 30893231 DOI: 10.2106/jbjs.18.00143] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The use of aspirin as prophylaxis against venous thromboembolism (VTE) following total joint arthroplasty (TJA) has increased in popularity; however, the potential cardioprotective effects of aspirin when administered as VTE prophylaxis remain unknown. The present study investigated the influence of VTE prophylaxis, including aspirin, on mortality following TJA. METHODS We retrospectively reviewed 31,133 patients who underwent primary TJA from 2000 to 2017. Patient demographics, body mass index, and comorbidities were obtained from an electronic chart query. Patients were allocated into 2 cohorts on the basis of the VTE prophylaxis administered: aspirin (25.9%, 8,061 patients) and non-aspirin (74.1%, 23,072 patients). Mortality was assessed with use of an institutional mortality database that is updated biannually. Univariate and multivariate regression analyses were performed. RESULTS The overall mortality rate was 0.2% and 0.6% at 30 days and 1 year after TJA, respectively. The use of aspirin was independently associated with lower risk of death at both 30 days (odds ratio [OR], 0.39; p = 0.020) and 1 year (OR, 0.51; p = 0.004). Patients in the non-aspirin cohort showed 3 times the risk of death at 30 days compared with the aspirin cohort (0.3% compared with 0.1%; p = 0.004), and twice the risk of death at 1 year (0.7% compared with 0.3%; p < 0.001). At 1 year, the primary cause of death in the non-aspirin group was cardiac-related (46 of 23,072, 0.20%). In the aspirin group, the rate of cardiac-related death was almost 5 times lower (3 of 8,061, 0.04%; p = 0.005). Risk factors for mortality at 1 year included higher age (p < 0.001), male sex (p = 0.020), history of congestive heart failure (p = 0.003), cerebrovascular disease (p < 0.001), malignancy (p < 0.001), and history of prior myocardial infarction (p < 0.001). CONCLUSIONS The present study demonstrates that the use of aspirin as prophylaxis against VTE following TJA may reduce the risk of mortality. Given the numerous options available and permitted by the current guidelines, orthopaedic surgeons should be aware of the potential added benefits of aspirin when selecting a VTE-prophylactic agent. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander J Rondon
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Noam Shohat
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Timothy L Tan
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Karan Goswami
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Javad Parvizi
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Dawoud DM, Wonderling D, Glen J, Lewis S, Griffin XL, Hunt BJ, Stansby G, Reed M, Rossiter N, Chahal JK, Sharpin C, Barry P. Cost-Utility Analysis of Venous Thromboembolism Prophylaxis Strategies for People Undergoing Elective Total Hip and Total Knee Replacement Surgeries in the English National Health Service. Front Pharmacol 2018; 9:1370. [PMID: 30564117 PMCID: PMC6289021 DOI: 10.3389/fphar.2018.01370] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/07/2018] [Indexed: 12/21/2022] Open
Abstract
Background: Major orthopedic surgery, such as elective total hip replacement (eTHR) and elective total knee replacement (eTKR), are associated with a higher risk of venous thromboembolism (VTE) than other surgical procedures. Little is known, however, about the cost-effectiveness of VTE prophylaxis strategies in people undergoing these procedures. Aim: The aim of this work was to assess the cost-effectiveness of these strategies from the English National Health Service perspective to inform NICE guideline (NG89) recommendations. Materials and Methods: Cost-utility analysis, using decision modeling, was undertaken to compare 15 VTE prophylaxis strategies for eTHR and 12 for eTKR, in addition to "no prophylaxis" strategy. The analysis complied with the NICE Reference Case. Structure and assumptions were agreed with the guideline committee. Incremental net monetary benefit (INMB) was calculated, vs. the model comparator (LMWH+ antiembolism stockings), at a threshold of £20,000/quality-adjusted life-year (QALY) gained. The model was run probabilistically. Deterministic sensitivity analyses (SAs) were undertaken to assess the robustness of the results. Results: The most cost-effective strategies were LMWH for 10 days followed by aspirin for 28 days (INMB = £530 [95% CI: -£784 to £1,103], probability of being most cost-effective = 72%) for eTHR, and foot pump (INMB = £353 [95% CI: -£101 to £665]; probability of being most cost-effective = 18%) for eTKR. There was considerable uncertainty regarding the cost-effectiveness ranking in the eTKR analysis. The results were robust to change in all SAs. Conclusions: For eTHR, LMWH (standard dose) for 10 days followed by aspirin for 28 days is the most cost-effective VTE prophylaxis strategy. For eTKR, the results are highly uncertain but foot pump appeared to be the most cost-effective strategy, followed closely by aspirin (low dose). Future research should focus on assessing cost-effectiveness of VTE prophylaxis in the eTKR population.
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Affiliation(s)
- Dalia M. Dawoud
- Clinical Pharmacy Department, Faculty of Pharmacy, Cairo University, Giza, Egypt
- Clinical and Pharmaceutical Sciences Department, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - David Wonderling
- National Guideline Centre, Royal College of Physicians-London, London, United Kingdom
| | - Jessica Glen
- National Guideline Centre, Royal College of Physicians-London, London, United Kingdom
| | - Sedina Lewis
- National Guideline Centre, Royal College of Physicians-London, London, United Kingdom
| | - Xavier L. Griffin
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Beverley J. Hunt
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Gerard Stansby
- Northern Vascular Unit, Freeman Hospital, Newcastle University and Newcastle Hospitals, Newcastle upon Tyne, United Kingdom
| | - Michael Reed
- Northumbria Healthcare NHS Foundation Trust, North Shields, United Kingdom
| | - Nigel Rossiter
- Department of Trauma & Orthopaedic Surgery, Basingstoke & North Hampshire Hospital, Basingstoke, United Kingdom
| | | | - Carlos Sharpin
- National Guideline Centre, Royal College of Physicians-London, London, United Kingdom
| | - Peter Barry
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
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Roman F, Allen JS, Wurm HC, MacLaughlin K. Pulmonary Embolism While on Aspirin for Venous Thromboembolism Prophylaxis After Total Knee Arthroplasty. J Prim Care Community Health 2018; 9:2150132718797446. [PMID: 30168355 PMCID: PMC6120175 DOI: 10.1177/2150132718797446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A 62-year-old Caucasian man with past medical history significant for coronary artery disease, status post drug eluting stent to the left anterior descending artery 10 years prior, was admitted for elective total right knee arthroplasty. His intraoperative course was uneventful, and he was discharged on hospital day 2 on aspirin 325 mg twice daily for 6 weeks for venous thromboembolism (VTE) prophylaxis. Three weeks later the patient developed chest pain shortly after an approximately 1-hour flight and presented to a local emergency department where computed tomography angiogram showed pulmonary emboli involving segmental and subsegmental pulmonary arteries bilaterally. He was transitioned from aspirin 325 mg twice a day to rivaroxaban 15 mg twice daily for 21 days, with a plan to transition to 20 mg daily to complete a 3-month course. He returned to his primary care physician 6 days after discharge with questions about his current anticoagulation therapy as well as the regimen he was on prior to the pulmonary embolism. Two major organizations, The American Academy of Orthopedic Surgeons and The American College of Chest Physicians, provide recommendations for VTE prophylaxis, but they differ regarding the preferred pharmacologic modality and duration. Although the goal is to provide optimal patient care, lack of guideline consensus may lead to different postoperative recommendations. It is important for clinicians to discuss with their patients the pharmacologic options available for VTE prophylaxis, how organizations differ in their recommendations, and the limitations of these pharmacologic agents.
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Anderson DR, Dunbar M, Murnaghan J, Kahn SR, Gross P, Forsythe M, Pelet S, Fisher W, Belzile E, Dolan S, Crowther M, Bohm E, MacDonald SJ, Gofton W, Kim P, Zukor D, Pleasance S, Andreou P, Doucette S, Theriault C, Abianui A, Carrier M, Kovacs MJ, Rodger MA, Coyle D, Wells PS, Vendittoli PA. Aspirin or Rivaroxaban for VTE Prophylaxis after Hip or Knee Arthroplasty. N Engl J Med 2018; 378:699-707. [PMID: 29466159 DOI: 10.1056/nejmoa1712746] [Citation(s) in RCA: 274] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Clinical trials and meta-analyses have suggested that aspirin may be effective for the prevention of venous thromboembolism (proximal deep-vein thrombosis or pulmonary embolism) after total hip or total knee arthroplasty, but comparisons with direct oral anticoagulants are lacking for prophylaxis beyond hospital discharge. METHODS We performed a multicenter, double-blind, randomized, controlled trial involving patients who were undergoing total hip or knee arthroplasty. All the patients received once-daily oral rivaroxaban (10 mg) until postoperative day 5 and then were randomly assigned to continue rivaroxaban or switch to aspirin (81 mg daily) for an additional 9 days after total knee arthroplasty or for 30 days after total hip arthroplasty. Patients were followed for 90 days for symptomatic venous thromboembolism (the primary effectiveness outcome) and bleeding complications, including major or clinically relevant nonmajor bleeding (the primary safety outcome). RESULTS A total of 3424 patients (1804 undergoing total hip arthroplasty and 1620 undergoing total knee arthroplasty) were enrolled in the trial. Venous thromboembolism occurred in 11 of 1707 patients (0.64%) in the aspirin group and in 12 of 1717 patients (0.70%) in the rivaroxaban group (difference, 0.06 percentage points; 95% confidence interval [CI], -0.55 to 0.66; P<0.001 for noninferiority and P=0.84 for superiority). Major bleeding complications occurred in 8 patients (0.47%) in the aspirin group and in 5 (0.29%) in the rivaroxaban group (difference, 0.18 percentage points; 95% CI, -0.65 to 0.29; P=0.42). Clinically important bleeding occurred in 22 patients (1.29%) in the aspirin group and in 17 (0.99%) in the rivaroxaban group (difference, 0.30 percentage points; 95% CI, -1.07 to 0.47; P=0.43). CONCLUSIONS Among patients who received 5 days of rivaroxaban prophylaxis after total hip or total knee arthroplasty, extended prophylaxis with aspirin was not significantly different from rivaroxaban in the prevention of symptomatic venous thromboembolism. (Funded by the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT01720108 .).
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Affiliation(s)
- David R Anderson
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Michael Dunbar
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - John Murnaghan
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Susan R Kahn
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Peter Gross
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Michael Forsythe
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Stephane Pelet
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - William Fisher
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Etienne Belzile
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Sean Dolan
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Mark Crowther
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Eric Bohm
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Steven J MacDonald
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Wade Gofton
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Paul Kim
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - David Zukor
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Susan Pleasance
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Pantelis Andreou
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Steve Doucette
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Chris Theriault
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Abongnwen Abianui
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Marc Carrier
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Michael J Kovacs
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Marc A Rodger
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Doug Coyle
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Philip S Wells
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
| | - Pascal-Andre Vendittoli
- From the Departments of Medicine (D.R.A.), Surgery (M.D.), and Community Health and Epidemiology (P.A.), Dalhousie University, and the Nova Scotia Health Authority (S. Pleasance, S. Doucette, C.T., A.A.), Halifax, the Department of Surgery, University of Toronto, Toronto (J.M.), the Departments of Medicine (S.R.K.) and Surgery (W.F., D.Z.), McGill University, and the Department of Surgery, University of Montreal (P.-A.V.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (P.G., M. Crowther), the Department of Surgery, Dalhousie University, Moncton, NB (M.F.), the Department of Surgery, Laval University, Quebec, QC (S. Pelet, E. Belzile), the Department of Medicine, Dalhousie University, Saint John, NB (S. Dolan), the Department of Surgery, University of Manitoba, Winnipeg (E. Bohm), the Departments of Surgery (S.J.M.) and Medicine (M.J.K.), University of Western Ontario, London, and the Department of Surgery (W.G., P.K.), Division of Hematology, Department of Medicine (M. Carrier, M.A.R., P.S.W.), and School of Epidemiology and Public Health (D.C.), University of Ottawa, Ottawa - all in Canada
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Azboy I, Barrack R, Thomas AM, Haddad FS, Parvizi J. Aspirin and the prevention of venous thromboembolism following total joint arthroplasty: commonly asked questions. Bone Joint J 2017; 99-B:1420-1430. [PMID: 29092979 PMCID: PMC5742873 DOI: 10.1302/0301-620x.99b11.bjj-2017-0337.r2] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/19/2017] [Indexed: 12/17/2022]
Abstract
The number of arthroplasties being performed
increases each year. Patients undergoing an arthroplasty are at
risk of venous thromboembolism (VTE) and appropriate prophylaxis
has been recommended. However, the optimal protocol and the best
agent to minimise VTE under these circumstances are not known. Although
many agents may be used, there is a difference in their efficacy
and the risk of bleeding. Thus, the selection of a particular agent relies
on the balance between the desire to minimise VTE and the attempt
to reduce the risk of bleeding, with its undesirable, and occasionally
fatal, consequences. Acetylsalicylic acid (aspirin) is an agent for VTE prophylaxis
following arthroplasty. Many studies have shown its efficacy in
minimising VTE under these circumstances. It is inexpensive and
well-tolerated, and its use does not require routine blood tests.
It is also a ‘milder’ agent and unlikely to result in haematoma
formation, which may increase both the risk of infection and the
need for further surgery. Aspirin is also unlikely to result in persistent
wound drainage, which has been shown to be associated with the use
of agents such as low-molecular-weight heparin (LMWH) and other
more aggressive agents. The main objective of this review was to summarise the current
evidence relating to the efficacy of aspirin as a VTE prophylaxis
following arthroplasty, and to address some of the common questions
about its use. There is convincing evidence that, taking all factors into account,
aspirin is an effective, inexpensive, and safe form of VTE following
arthroplasty in patients without a major risk factor for VTE, such
as previous VTE. Cite this article: Bone Joint J 2017;99-B:1420–30.
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Affiliation(s)
- I Azboy
- Rothman Institute at Thomas Jefferson University Hospital, Sheridan Building, Suite 1000, 125 South 9th Street, Philadelphia, PA 19107, USA
| | - R Barrack
- Washington University Orthopedics, Barnes Jewish Hospital, 660 South Euclid Avenue, Campus Box 8233, St. Louis, Missouri 63110, USA
| | - A M Thomas
- The Royal Orthopaedic Hospital, Bristol Road South, Birmingham B31 2AP, UK
| | - F S Haddad
- University College London Hospitals, 235 Euston Road, London NW1 2BU, UK and NIHR University College London Hospitals Biomedical Research Centre, UK
| | - J Parvizi
- Rothman Institute at Thomas Jefferson University Hospital, Sheridan Building, Suite 1000, 125 South 9th Street, Philadelphia, PA 19107, USA
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Comparative Effectiveness and Safety of Drug Prophylaxis for Prevention of Venous Thromboembolism After Total Knee Arthroplasty. J Arthroplasty 2017. [PMID: 28634095 DOI: 10.1016/j.arth.2017.05.042] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Rates of venous thromboembolism in contemporary studies of primary total knee arthroplasty (TKA) have been reported to be as high as 3.5%. Although drug prophylaxis is effective, the best option among these regimens is not well established. The purpose of this study was to evaluate the comparative effectiveness and safety of aspirin, low-molecular-weight heparin, synthetic pentasaccharide factor Xa inhibitors, and vitamin K antagonist. METHODS Data were from a US total joint replacement registry, with 30,499 patients receiving unilateral TKA from May 16, 2006, to December 31, 2013. Patients received either aspirin (324-325 mg daily), enoxaparin (40-60 mg daily), fondaparinux (2.5 mg daily), or warfarin (all doses) and were followed up 90 days postoperatively on several outcomes: deep vein thrombosis, pulmonary embolism, major bleeding, wound complications, infection, and death. RESULTS There was no evidence that fondaparinux, enoxaparin, or warfarin were superior to aspirin in the prevention of pulmonary embolism, deep vein thrombosis, or venous thromboembolism or that aspirin was safer than these alternatives. However, enoxaparin was found to be as safe as aspirin with respect to bleeding, and fondaparinux was as safe as aspirin for risk of wound complications. CONCLUSION Among TKA patients, we did not find evidence for decreased effectiveness or increased safety with use of aspirin, but enoxaparin had comparable safety to aspirin for bleeding and fondaparinux had comparable safety to aspirin for wound complications.
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Parvizi J, Ceylan HH, Kucukdurmaz F, Merli G, Tuncay I, Beverland D. Venous Thromboembolism Following Hip and Knee Arthroplasty: The Role of Aspirin. J Bone Joint Surg Am 2017; 99:961-972. [PMID: 28590382 DOI: 10.2106/jbjs.16.01253] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Javad Parvizi
- 1The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania 2Bezmialem Vakif University, Istanbul, Turkey 3Thomas Jefferson University, Philadelphia, Pennsylvania 4Musgrave Park Hospital, Belfast, United Kingdom
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Odeh K, Doran J, Yu S, Bolz N, Bosco J, Iorio R. Risk-Stratified Venous Thromboembolism Prophylaxis After Total Joint Arthroplasty: Aspirin and Sequential Pneumatic Compression Devices vs Aggressive Chemoprophylaxis. J Arthroplasty 2016; 31:78-82. [PMID: 27067751 DOI: 10.1016/j.arth.2016.01.065] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 12/30/2015] [Accepted: 01/18/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major concern after total joint arthroplasty (TJA). We evaluated a risk-stratified prophylaxis protocol for patients undergoing TJA. METHODS A total of 2611 TJA patients were retrospectively studied. Patients treated with an aggressive VTE chemoprophylaxis protocol were compared with patients treated with a risk-stratified protocol utilizing aspirin and sequential pneumatic compression devices (SPCDs) for standard-risk patients and targeted anticoagulation for high-risk patients. RESULTS We found equivalence in terms of VTE prevention between the 2 cohorts. There was a decrease in adverse events and readmissions among the risk-stratified cohort, although this did not reach statistical significance. A statistically significant reduction in costs (P < .001) was experienced with the use of aspirin/SPCDs compared with aggressive anticoagulation agents within the risk-stratified cohort. CONCLUSION The use of aspirin/SPCDs in a risk-stratified TJA population is a safe and cost-effective method of VTE prophylaxis.
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Affiliation(s)
- Khalid Odeh
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - James Doran
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Stephen Yu
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Nicholas Bolz
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Joseph Bosco
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Richard Iorio
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
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Wilson DGG, Poole WEC, Chauhan SK, Rogers BA. Systematic review of aspirin for thromboprophylaxis in modern elective total hip and knee arthroplasty. Bone Joint J 2016; 98-B:1056-61. [DOI: 10.1302/0301-620x.98b8.36957] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 04/06/2016] [Indexed: 12/31/2022]
Abstract
Aims There is uncertainty regarding the optimal means of thromboprophylaxis following total hip and knee arthroplasty (THA, TKA). This systematic review presents the evidence for acetylsalicylic acid (aspirin) as a thromboprophylactic agent in THA and TKA and compares it with other chemoprophylactic agents. Materials and Methods A search of literature published between 2004 and 2014 was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 13 studies were eligible for inclusion. Results Evidence from one good quality randomised controlled trial (RCT) showed no difference in rates of venous thrombo-embolism (VTE) in patients given aspirin or low molecular weight heparin (LMWH) following TKA. There was insufficient evidence from trials with moderate to severe risk of bias being present to suggest aspirin is more or less effective than LMWH, warfarin or dabigatran for the prevention of VTE in TKA or THA. Compared with aspirin, rates of asymptomatic deep vein thrombosis (DVT) in TKA may be reduced with rivaroxaban but insufficient evidence exists to demonstrate an effect on incidence of symptomatic DVT. Compared with aspirin there is evidence of more wound complications following THA and TKA with dabigatran and in TKA with rivaroxaban. Some studies highlighted concerns over bleeding complications and efficacy of aspirin. Conclusion The results suggest aspirin may be considered a suitable alternative to other thromboprophylactic agents following THA and TKA. Further investigation is required to fully evaluate the safety and efficacy of aspirin. Cite this article: Bone Joint J 2016;98-B:1056–61.
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Affiliation(s)
- D. G. G. Wilson
- Brighton and Sussex University Hospitals
NHS Trust, Department of Trauma and Orthopaedics, Eastern
Road, Brighton, BN2 5BE, UK
| | - W. E. C. Poole
- Brighton and Sussex University Hospitals
NHS Trust, Eastern Road, Brighton, East Sussex, BN2
5BE, UK
| | - S. K. Chauhan
- Brighton and Sussex University Hospitals
NHS Trust, Eastern Road, Brighton, East Sussex, BN2
5BE, UK
| | - B. A. Rogers
- Brighton and Sussex University Hospitals
NHS Trust, Eastern Road, Brighton, East Sussex, BN2
5BE, UK
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Bayley E, Brown S, Bhamber NS, Howard PW. Fatal pulmonary embolism following elective total hip arthroplasty. Bone Joint J 2016; 98-B:585-8. [DOI: 10.1302/0301-620x.98b5.34996] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 11/11/2015] [Indexed: 12/27/2022]
Abstract
Aims The place of thromboprophylaxis in arthroplasty surgery remains controversial, with a challenging requirement to balance prevention of potentially fatal venous thrombo-embolism with minimising wound-related complications leading to deep infection. We compared the incidence of fatal pulmonary embolism in patients undergoing elective primary total hip arthroplasty (THA) between those receiving aspirin, warfarin and low molecular weight heparin (LMWH) for the chemical component of a multi-modal thromboprophylaxis regime. Patients and Methods A prospective audit database was used to identify patients who had died within 42 and 90 days of surgery respectively between April 2000 and December 2012. A case note review was performed to ascertain the causes of death. Results During this period 7983 THAs were performed. The rate of mortality was 0.43% and 0.58% at 42 and 90 days respectively. The groups comprised 1571 patients (19.7%) on warfarin, 1838 (23.0%) on LMWH and 4574 (57.3%) on aspirin. The 90-day mortality for these three groups was 0.38%, 1.09% and 0.43% respectively. The higher mortality rate for LMWH was significant (p < 0.05). There were six fatal pulmonary emboli (PEs) (0.08%). A total of three occurred within 42 days, all in the LMWH group. A total of three occurred between 42 and 90 days; one on warfarin, two on LMWH. The leading causes of death in all three groups were lower respiratory tract infections and myocardial infarction. Conclusion We confirmed that fatal PE following elective THA with a multi-modal prophylaxis regime is rare. We further found that LMWH conferred no benefit over aspirin in this context, and is associated with a higher all-cause rate of mortality. Take home message: This study proposes that aspirin may be an appropriate thromboprophylaxis agent when used as part of a multi-modal regimen, suggesting current guidelines should be reviewed. Cite this article: Bone Joint J 2016;98-B:585–8.
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Affiliation(s)
- E. Bayley
- The Royal Derby Hospital, Uttoxeter
Road, Derby, DE22 3NE, UK
| | - S. Brown
- Royal Hallamshire Hospital, Sheffield
S10 2JF, UK
| | - N. S. Bhamber
- St George’s University Hospital NHS FoundationTrust, Blackshaw Road,
Tooting London SW17 0QT, UK
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43
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Sahebally SM, Healy D, Walsh SR. Aspirin in the primary prophylaxis of venous thromboembolism in surgical patients. Surgeon 2015; 13:348-58. [DOI: 10.1016/j.surge.2015.05.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 05/13/2015] [Accepted: 05/16/2015] [Indexed: 12/16/2022]
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Pellegrini VD. Prophylaxis Against Venous Thromboembolism After Total Hip and Knee Arthroplasty: A Critical Analysis Review. JBJS Rev 2015; 3:01874474-201509000-00001. [PMID: 27490672 DOI: 10.2106/jbjs.rvw.n.00111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Vincent D Pellegrini
- Department of Orthopaedics, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC 29425
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45
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Zhang ZH, Shen B, Yang J, Zhou ZK, Kang PD, Pei FX. Risk factors for venous thromboembolism of total hip arthroplasty and total knee arthroplasty: a systematic review of evidences in ten years. BMC Musculoskelet Disord 2015; 16:24. [PMID: 25887100 PMCID: PMC4328702 DOI: 10.1186/s12891-015-0470-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 01/15/2015] [Indexed: 02/05/2023] Open
Abstract
Background Risk factors for venous thromboembolism (VTE) of total joint arthroplasty (TJA) have been examined by many studies. A comprehensive systematic review of recent findings of high evidence level in this topic is needed. Methods We conducted a PubMed search for papers published between 2003 and 2013 that provided level-I and level-II evidences on risk factors for VTE of TJA. For each potential factors examined in at least three papers, we summarize the the number of the papers and confirmed the direction of statistically significant associations, e.g. “risk factor” “protective factor” or “controversial factor”. Results Fifty-four papers were included in the systematic review. Risk factors found to be associated with VTE of both total hip arthroplasty and total knee arthroplasty included older age, female sex, higher BMI, bilateral surgery, surgery time > 2 hours. VTE history was found as a VTE risk factor of THA but an controversial factor of TKA. Cemented fixation as compared to cementless fixation was found as a risk factor for VTE only of TKA. TKA surgery itself was confirmed as a VTE risk factor compared with THA surgery. Conclusions This systematic review of high level evidences published in recent ten years identified a range of potential factors associated with VTE risk of total joint arthroplasty. These results can provide informations in this topic for doctors, patients and researchers.
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Affiliation(s)
- Zi-hao Zhang
- Department of Orthopaedics surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, P.R.China.
| | - Bin Shen
- Department of Orthopaedics surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, P.R.China.
| | - Jing Yang
- Department of Orthopaedics surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, P.R.China.
| | - Zong-ke Zhou
- Department of Orthopaedics surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, P.R.China.
| | - Peng-de Kang
- Department of Orthopaedics surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, P.R.China.
| | - Fu-xing Pei
- Department of Orthopaedics surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, P.R.China.
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47
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Prevention of venous thromboembolic events following femoroacetabular osteoplasty: aspirin is enough for most. Hip Int 2014; 24:77-80. [PMID: 23934900 DOI: 10.5301/hipint.5000079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND As hip-preservation surgery is performed in a particularly young and active group of patients, the knowledge accrued in the fields of hip arthroplasty and hip fracture care regarding postoperative thromboprophylaxis cannot be extrapolated to this patient population. Recommendations based on the evidence for each particular surgical procedure and population is desirable. For these reasons, the purpose of our study is to describe the rate of clinically relevant venous thromboembolism (VTE) and anticoagulation-related complications observed in patients undergoing hip-preservation surgery through mini-open femoracetabular osteoplasty (FAO) with a formal postoperative thromboprophylaxis protocol of aspirin dosing. METHODS A prospective case series of 407 consecutive FAO procedures in 375 patients of mean age 34.5 ± 11.1 years (range 15-62 years) were followed six weeks post operatively to document the presence of clinically relevant VTE as well as major bleeding events, as defined by the most recent American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. All patients were given aspirin 325 mg by mouth daily for two to four weeks. RESULTS There was one case of distal DVT in a 31-year-old male with no specific risk factors. No cases of pulmonary embolism were observed. There were no major bleeding events or reoperations due to postsurgical haematoma. There were no deaths. The crude incidence of clinically relevant VTE was 1 per 407 procedures (0.25%). CONCLUSION Aspirin is a safe and effective modality to provide thromboprophylaxis in patients undergoing hip-preservation surgery. The rate of VTE that we observed is, thus far, the lowest in comparison to other published series of hip preservation surgery that specifically focused on this complication.
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Jameson SS, Baker PN, Deehan DJ, Port A, Reed MR. Evidence-base for aspirin as venous thromboembolic prophylaxis following joint replacement. Bone Joint Res 2014; 3:146-9. [PMID: 24837005 PMCID: PMC4054010 DOI: 10.1302/2046-3758.35.2000225] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The National Institute for Health and Clinical
Excellence (NICE) has thus far relied on historical data and predominantly
industry-sponsored trials to provide evidence for venous thromboembolic
(VTE) prophylaxis in joint replacement patients. We argue that the
NICE guidelines may be reliant on assumptions that are in need of
revision. Following the publication of large scale, independent
observational studies showing little difference between low-molecular-weight
heparins and aspirin, and recent changes to the guidance provided
by other international bodies, should NICE reconsider their recommendations? Cite this article: Bone Joint Res 2014;3:146–9.
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Affiliation(s)
- S S Jameson
- South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough TS4 3BW, UK
| | - P N Baker
- South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough TS4 3BW, UK
| | - D J Deehan
- Newcastle Hospitals NHS Foundation Trust, Freeman Road, High Heaton, Newcastle upon Tyne, NE7 7DN, UK
| | - A Port
- South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough TS4 3BW, UK
| | - M R Reed
- Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, NE63 9JJ, UK
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Budhiparama NC, Abdel MP, Ifran NN, Parratte S. Venous Thromboembolism (VTE) Prophylaxis for Hip and Knee Arthroplasty: Changing Trends. Curr Rev Musculoskelet Med 2014; 7:108-16. [PMID: 24706152 DOI: 10.1007/s12178-014-9207-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Venous thromboembolism (VTE) has been identified as an immediate threat to patients undergoing major orthopedic procedures such as total hip arthroplasty (THA) and total knee arthroplasty (TKA). Given the known dangers of VTE, arthroplasty surgeons are sensitive to the need for VTE thromboprophylaxis. However, the modalities of thromboprophylaxis used to minimize the risks to patients have been variable. Clinical practice guidelines have been published by several professional organizations, while some hospitals have established their own protocols. The 2 most popular guidelines are those published by the Academy of Orthopaedic Surgeons (AAOS) and American College of Chest Physicians (ACCP), both from North America. Prior to 2012, these recommendations varied depending on underlying definitions, methodology, and goals of the 2 groups. For the first time, both groups have similar recommendations that focus on minimizing symptomatic VTE and bleeding complications. The key to determining the appropriate chemoprophylaxis for patients is to balance efficacy of a prophylactic agent, while being safe in regards to bleeding complications. However, a multimodal approach that focuses on early postoperative mobilization and the use of mechanical prophylaxis, in addition to chemoprophylaxis, is essential.
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Affiliation(s)
- Nicolaas C Budhiparama
- Nicolaas Institute of Constructive Orthopaedics Research and Education Foundation for Arthroplasty & Sports Medicine, Medistra Hospital, Jl. Jend. Gatot Subroto Kav. 59, Jakarta, 12950, Indonesia,
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Use of aspirin for the prevention of lower extremity deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2014; 2:230-9. [PMID: 26993195 DOI: 10.1016/j.jvsv.2013.10.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 10/09/2013] [Accepted: 10/27/2013] [Indexed: 01/13/2023]
Abstract
Whereas aspirin is recommended and widely used to prevent arterial thrombosis, its role in the prevention of deep venous thrombosis is not well defined. Aspirin is well accepted, easy to manage with few risks and low cost, and thus ideal for thromboprophylaxis if evidence shows it is effective. Recent guidelines and large studies were reviewed. Recent guidelines include aspirin as an acceptable thromboprophylactic agent after hip and knee orthopedic surgery despite continued publication of underpowered and contradictory studies. Two large randomized controlled trials pooled together suggest that low-dose (100 mg) aspirin is a reasonable alternative to prevent recurrence of venous thromboembolism (VTE) in patients who have been treated for a first episode of unprovoked VTE. We suggest that the current practice using aspirin to prevent thromboembolism include cautious discussion of the benefits and risks of this agent before use in a patient until precise clarification of dosage and treatment length is available. Despite inclusion of aspirin in the guidelines for orthopedic surgery, there is little evidence to support its use for primary prevention of VTE. Until definitive unbiased trials are published, we suggest that aspirin remain a realistic option to use for secondary prevention of VTE, especially compared with the option of using no prophylaxis.
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